Basic Information
| Provider Information | |||||||||
| NPI: | 1063476042 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SASSACK | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2425 | ||||||||
| Address2: | |||||||||
| City: | SKYLAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287762425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285752644 | ||||||||
| FaxNumber: | 8283502174 | ||||||||
| Practice Location | |||||||||
| Address1: | 1521 E TANGERINE RD | ||||||||
| Address2: | SUITE 311 | ||||||||
| City: | ORO VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857556225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203261266 | ||||||||
| FaxNumber: | 5203262575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 11/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 49772 | AZ | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | Z173338 | 01 | AZ | MEDICARE PTAN | OTHER |