Healthcare Provider Details

I. General information

NPI: 1144535220
Provider Name (Legal Business Name): KENNETH J VANDERBECK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2010
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23181 VERDUGO DR STE 103A
LAGUNA HILLS CA
92653-1313
US

IV. Provider business mailing address

8765 AERO DR SUITE 130
SAN DIEGO CA
92123
US

V. Phone/Fax

Practice location:
  • Phone: 949-366-1053
  • Fax:
Mailing address:
  • Phone: 858-541-0181
  • Fax: 858-430-0919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9105536
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA21190
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: