Healthcare Provider Details

I. General information

NPI: 1538839907
Provider Name (Legal Business Name): LUCAS KAARSBERG ANDERSEN MMS,PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1635 E MYRTLE AVE
PHOENIX AZ
85020-5556
US

IV. Provider business mailing address

1635 E MYRTLE AVE STE 400
PHOENIX AZ
85020-5514
US

V. Phone/Fax

Practice location:
  • Phone: 602-944-2900
  • Fax:
Mailing address:
  • Phone: 317-224-4669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number8782
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: