Doctor Name: | JAMIE VANDERWIELEN |
NPI Number: | 1659570554 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | PA |
License Number: | 99027746A |
Business Practice Address: | 1600 Albany St Beech Grove, IN - 461071541 |
Business Phone Number: | 3177838148 |
Business Fax Number: | 3178700499 |
Mailing Address: | Po Box 7112, Dpt 31 INDIANAPOLIS |
State: | IN |
Postal Code: | 462077112 |
Phone Number: | 3178023151 |
Fax Number: | 3178700499 |
NPI Enumeration Date: | 07/12/2007 |
NPI Last Update Date: | 06/16/2008 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363AM0700X |
License Number: | 99027746A |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | IN |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Physician Assistant |
Taxonomy Specialization: | Medical |
Taxonomy Definition: |