Healthcare Provider Details

I. General information

NPI: 1073485447
Provider Name (Legal Business Name): BENJAMIN VANDERPOOL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 HOSPITAL DR
UTICA NY
13502-2517
US

IV. Provider business mailing address

871 MAPLEDALE RD
CASSVILLE NY
13318-1409
US

V. Phone/Fax

Practice location:
  • Phone: 315-917-9966
  • Fax:
Mailing address:
  • Phone: 315-269-1591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number035007
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: