Provider Demographics
NPI:1023210036
Name:PHOENIX ANESTHESIA ASSOCIATES PLLC
Entity Type:Organization
Organization Name:PHOENIX ANESTHESIA ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:LARGE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-981-9151
Mailing Address - Street 1:PO BOX 40670
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85274-0670
Mailing Address - Country:US
Mailing Address - Phone:480-981-9151
Mailing Address - Fax:480-324-5459
Practice Address - Street 1:4002 E MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-8612
Practice Address - Country:US
Practice Address - Phone:480-981-9151
Practice Address - Fax:480-324-5459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3086207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty