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General NPI Number Information
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NPI Number | 1083754287
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Entity Type | Individual
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Provider Name | ERIC DAVID VANFOSSEN PA-C
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Gender | Male
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Dates
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Enumeration Date | 02/07/2007
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Last Update Date | 12/02/2020
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Provider Practice Location Address
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Address Line | 1205 FAIRINGTON DR
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City | SIDNEY
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State | OH
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Zip | 45365-8144
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Country | US
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Telephone | 937-492-8431
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Fax |
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Provider Business Mailing Address
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Address Line | 21039 GEYER DR
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City | WAPAKONETA
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State | OH
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Zip | 45895-8815
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Country | US
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Telephone | 937-596-5386
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 0805
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License Number State | OH
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