Healthcare Provider Details

I. General information

NPI: 1396296836
Provider Name (Legal Business Name): MICHAEL LEE SANDRIDGE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2016
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8687 E VIA DE VENTURA SUITE 318
SCOTTSDALE AZ
85258-3347
US

IV. Provider business mailing address

8687 E VIA DE VENTURA STE 318
SCOTTSDALE AZ
85258-3351
US

V. Phone/Fax

Practice location:
  • Phone: 480-905-8755
  • Fax: 480-905-8851
Mailing address:
  • Phone: 480-905-8755
  • Fax: 480-905-8851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6577
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: