Provider Demographics
NPI:1154054591
Name:SUDHEER, MINI
Entity Type:Individual
Prefix:
First Name:MINI
Middle Name:
Last Name:SUDHEER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 E GAIL DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-1879
Mailing Address - Country:US
Mailing Address - Phone:480-246-7658
Mailing Address - Fax:
Practice Address - Street 1:655 S DOBSON RD STE 201
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5669
Practice Address - Country:US
Practice Address - Phone:480-307-9477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-04
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ276794363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ164370Medicaid