Healthcare Provider Details

I. General information

NPI: 1215614037
Provider Name (Legal Business Name): NATHAN VANDEGRAAFF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9520 W PALM LN STE 150
PHOENIX AZ
85037-4454
US

IV. Provider business mailing address

9520 W PALM LN STE 150
PHOENIX AZ
85037-4454
US

V. Phone/Fax

Practice location:
  • Phone: 602-584-5444
  • Fax: 602-584-6202
Mailing address:
  • Phone: 602-584-5444
  • Fax: 602-584-6202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9728
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: