Healthcare Provider Details

I. General information

NPI: 1710940192
Provider Name (Legal Business Name): LANNY L ODEN C-FA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1186 E REDFIELD RD
TEMPE AZ
85283-5732
US

IV. Provider business mailing address

1186 E REDFIELD RD
TEMPE AZ
85283-5732
US

V. Phone/Fax

Practice location:
  • Phone: 480-545-2610
  • Fax: 480-545-2673
Mailing address:
  • Phone: 480-545-2610
  • Fax: 480-545-2673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: