Provider Demographics
NPI:1306003678
Name:LODGE, KARLA M (PA-C)
Entity Type:Individual
Prefix:
First Name:KARLA
Middle Name:M
Last Name:LODGE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2527
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85252-2527
Mailing Address - Country:US
Mailing Address - Phone:602-703-3197
Mailing Address - Fax:
Practice Address - Street 1:2640 W BASELINE RD STE 111
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-6492
Practice Address - Country:US
Practice Address - Phone:480-677-8282
Practice Address - Fax:888-316-1686
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2427363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ688103Medicaid
P31141Medicare UPIN