Provider Demographics
NPI:1710940192
Name:ODEN, LANNY L (C-FA)
Entity Type:Individual
Prefix:
First Name:LANNY
Middle Name:L
Last Name:ODEN
Suffix:
Gender:M
Credentials:C-FA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1186 E REDFIELD RD
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-5732
Mailing Address - Country:US
Mailing Address - Phone:480-545-2610
Mailing Address - Fax:480-545-2673
Practice Address - Street 1:1186 E REDFIELD RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-5732
Practice Address - Country:US
Practice Address - Phone:480-545-2610
Practice Address - Fax:480-545-2673
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical