Provider Demographics
NPI:1265798664
Name:ARIZONA STATE UNIVERSITY
Entity type:Organization
Organization Name:ARIZONA STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER NP HEALTHCARE
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNGER
Authorized Official - Suffix:
Authorized Official - Credentials:MHA FACHE
Authorized Official - Phone:602-496-0721
Mailing Address - Street 1:500 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-2135
Mailing Address - Country:US
Mailing Address - Phone:602-496-0721
Mailing Address - Fax:
Practice Address - Street 1:500 N 3RD ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-2135
Practice Address - Country:US
Practice Address - Phone:602-496-0721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4432261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health