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
1	363A00000X	Physician Assistant	5601003590	MI

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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