Healthcare Provider Details

I. General information

NPI: 1851686414
Provider Name (Legal Business Name): IAN VANDERWOUDE PA-C, MSPAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2011
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9210 GOLF COURSE RD NW
ALBUQUERQUE NM
87114-5891
US

IV. Provider business mailing address

9210 GOLF COURSE RD NW
ALBUQUERQUE NM
87114-5891
US

V. Phone/Fax

Practice location:
  • Phone: 505-899-3933
  • Fax:
Mailing address:
  • Phone: 505-899-3933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2011-0015
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: