Provider Demographics
NPI:1710933361
Name:VAN ARSDELL, LANCE PHILLIP (PT)
Entity Type:Individual
Prefix:MR
First Name:LANCE
Middle Name:PHILLIP
Last Name:VAN ARSDELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6303 E MALLORY ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-2114
Mailing Address - Country:US
Mailing Address - Phone:602-619-8582
Mailing Address - Fax:480-654-0054
Practice Address - Street 1:6303 E MALLORY ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-2114
Practice Address - Country:US
Practice Address - Phone:602-619-8582
Practice Address - Fax:480-654-0054
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2821225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ529703Medicaid
AZ79405Medicare ID - Type UnspecifiedMEDICARE
AZ61468Medicare UPIN