Provider Demographics
NPI:1285054049
Name:SAN TAN FOOT AND ANKLE
Entity type:Organization
Organization Name:SAN TAN FOOT AND ANKLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:480-917-2300
Mailing Address - Street 1:3200 S ALMA SCHOOL RD
Mailing Address - Street 2:203
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-3757
Mailing Address - Country:US
Mailing Address - Phone:480-917-2300
Mailing Address - Fax:
Practice Address - Street 1:325 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6510
Practice Address - Country:US
Practice Address - Phone:480-917-2300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN TAN FOOT AND ANKLE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0672213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ805048Medicaid