1164400628 NPI number — SUSAN LASSITER CRNA

Table of content: SUSAN LASSITER CRNA (NPI 1164400628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164400628 NPI number — SUSAN LASSITER CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LASSITER
Provider First Name:
SUSAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164400628
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 53568
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85072-3568
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-544-5075
Provider Business Mailing Address Fax Number:
623-544-5093

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10401 W THUNDERBIRD BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUN CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85351-3004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-977-7211
Provider Business Practice Location Address Fax Number:
623-876-5697
Provider Enumeration Date:
01/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  RN114917 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 991910 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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