Provider Demographics
NPI:1306088307
Name:JEPPESEN, NATHAN SANFORD (DPM)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:SANFORD
Last Name:JEPPESEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18444 N 25TH AVE
Mailing Address - Street 2:STE 310
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1266
Mailing Address - Country:US
Mailing Address - Phone:623-537-5600
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:1450 S DOBSON RD
Practice Address - Street 2:STE B123
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4712
Practice Address - Country:US
Practice Address - Phone:623-537-5600
Practice Address - Fax:866-939-2673
Is Sole Proprietor?:No
Enumeration Date:2009-04-06
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0745213ES0103X, 213ES0131X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ715319Medicaid
AZZ90096Medicare PIN