Provider Demographics
NPI:1063689909
Name:SANDRIDGE, LAYNE C (MD)
Entity Type:Individual
Prefix:
First Name:LAYNE
Middle Name:C
Last Name:SANDRIDGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19801 N 59TH AVE UNIT 11659
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85318-5068
Mailing Address - Country:US
Mailing Address - Phone:623-688-5075
Mailing Address - Fax:623-688-5075
Practice Address - Street 1:18700 N 64TH DR STE 105A
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7110
Practice Address - Country:US
Practice Address - Phone:623-688-5075
Practice Address - Fax:623-688-5075
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-09
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ408612086S0129X
AZ390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ398159Medicaid
AZZ216660OtherMEDICARE
AZ398159Medicaid