Provider Demographics
NPI:1205676277
Name:ANDERSON, LAUREN L (PA)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1303
Mailing Address - Country:US
Mailing Address - Phone:602-649-2007
Mailing Address - Fax:
Practice Address - Street 1:2945 S DOBSON RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-7941
Practice Address - Country:US
Practice Address - Phone:480-969-4138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-28
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
AZ10554363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty