Healthcare Provider Details

I. General information

NPI: 1487050746
Provider Name (Legal Business Name): ALYSSA VAN HEERDEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2014
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NE NEFF RD
BEND OR
97701-6015
US

IV. Provider business mailing address

7901 FROST ST
SAN DIEGO CA
92123-2701
US

V. Phone/Fax

Practice location:
  • Phone: 541-388-4333
  • Fax: 541-388-3446
Mailing address:
  • Phone: 858-939-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number52135
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: