Healthcare Provider Details

I. General information

NPI: 1275171993
Provider Name (Legal Business Name): ADVANCED RECONSTRUCTION AND AESTHETICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2019
Last Update Date: 09/26/2026
Certification Date: 09/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4630 E INDIAN SCHOOL RD
PHOENIX AZ
85018-5416
US

IV. Provider business mailing address

4630 E INDIAN SCHOOL RD
PHOENIX AZ
85018-5416
US

V. Phone/Fax

Practice location:
  • Phone: 602-584-8883
  • Fax: 602-899-4161
Mailing address:
  • Phone: 602-584-8883
  • Fax: 602-899-4161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: RANDALL OLIVER CRAFT
Title or Position: OWNER
Credential: MD
Phone: 602-584-8883