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NPI Code Detail

MEDICARE: BRENT WARD VANDYKE PA-C

MEDICARE: BRENT WARD VANDYKE PA-C
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
1363A00000XPhysician Assistant5601003590MI

General Provider Information

NPI Number : 1588651665
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRENT WARD VANDYKE PA-C
Provider Business Mailing Address
First Line : 100 MICHIGAN ST NE # MC845
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49503-2560
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2770 E BELTLINE AVE NE
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49525-8614
Country : US
Telephone Number : 616-267-8860
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/04/2005
Last Update Date : 11/05/2024

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Directions to “ BRENT WARD VANDYKE PA-C” Practice Location

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