Healthcare Provider Details

I. General information

NPI: 1376315598
Provider Name (Legal Business Name): BENJAMIN VANDERSOMMEN FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26224 N TATUM BLVD
PHOENIX AZ
85050-7500
US

IV. Provider business mailing address

26224 N TATUM BLVD
PHOENIX AZ
85050-7500
US

V. Phone/Fax

Practice location:
  • Phone: 480-663-9632
  • Fax: 480-419-6782
Mailing address:
  • Phone: 480-663-9632
  • Fax: 480-419-6782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number298887
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: