Healthcare Provider Details

I. General information

NPI: 1154805281
Provider Name (Legal Business Name): JONATHAN VANDALE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2018
Last Update Date: 09/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 FENWOOD RD FL 2
BOSTON MA
02115-6128
US

IV. Provider business mailing address

831 E 2ND ST # 2
SOUTH BOSTON MA
02127-2333
US

V. Phone/Fax

Practice location:
  • Phone: 617-732-5322
  • Fax:
Mailing address:
  • Phone: 413-262-9376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberPA6762
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: