Healthcare Provider Details

I. General information

NPI: 1386928703
Provider Name (Legal Business Name): SHAWN VANGRONIGEN P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2011
Last Update Date: 08/12/2022
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 MALL DR STE 111
HANFORD CA
93230-5916
US

IV. Provider business mailing address

3827 N 10TH ST STE 305
MCALLEN TX
78501-1745
US

V. Phone/Fax

Practice location:
  • Phone: 559-583-7546
  • Fax:
Mailing address:
  • Phone: 956-803-0748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA21123
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: