=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144667858
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDON WILLEM VANDERWEL M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2013
-----------------------------------------------------
Last Update Date | 08/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19930 BALLINGER WAY NE
-----------------------------------------------------
City | SHORELINE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98155-1223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-778-2220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1965 COULSTON ST APT 14
-----------------------------------------------------
City | LOMA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92354-1741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | MD60786062
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------