MEDICARE: MS. DESIREE ETTALEE VAN DYNE PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	TC224	KY
2	363A00000X	Physician Assistant	PA3049	KY
3	363A00000X	Physician Assistant	50.003418RX	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528343613
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DESIREE ETTALEE VAN DYNE PA

Provider Business Mailing Address
First Line	:	3535 OLENTANGY RIVER RD STE 2010
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43214-3998
Country	:	US
Telephone Number	:	614-566-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	3535 OLENTANGY RIVER RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43214-3998
Country	:	US
Telephone Number	:	614-566-5000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2011
Last Update Date	:	10/02/2023

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