Healthcare Provider Details

I. General information

NPI: 1295856532
Provider Name (Legal Business Name): HARRY ERNEST VANDERVORT III FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DUKE VANDERVORT

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 E 30TH AVE
EUGENE OR
97405-0640
US

IV. Provider business mailing address

4000 E 30TH AVE
EUGENE OR
97405-0640
US

V. Phone/Fax

Practice location:
  • Phone: 541-463-5665
  • Fax: 541-463-4164
Mailing address:
  • Phone: 541-463-5665
  • Fax: 541-463-4164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number88-000106
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier88-000106
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerNURSE PRACTITIONER LICENS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: