Provider Demographics
NPI:1578270195
Name:LOFSTEDT, ADDISON (PA-C)
Entity Type:Individual
Prefix:
First Name:ADDISON
Middle Name:
Last Name:LOFSTEDT
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 1:4566 E INVERNESS AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4634
Mailing Address - Country:US
Mailing Address - Phone:480-933-1300
Mailing Address - Fax:
Practice Address - Street 1:4566 E INVERNESS AVE STE 208
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4634
Practice Address - Country:US
Practice Address - Phone:480-933-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9430363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty