Healthcare Provider Details

I. General information

NPI: 1730602376
Provider Name (Legal Business Name): HAYLEY RAE VANDENBERG PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HAYLEY RAE JOHNSON

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 DIVISADERO ST
SAN FRANCISCO CA
94143-3010
US

IV. Provider business mailing address

1600 DIVISADERO ST
SAN FRANCISCO CA
94143-3010
US

V. Phone/Fax

Practice location:
  • Phone: 415-353-4201
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18331
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA57700
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: