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General NPI Number Information
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NPI Number | 1780179333
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Entity Type | Individual
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Provider Name | STORM BRADLEY VAUGHN AA
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Gender | Male
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Dates
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Enumeration Date | 06/26/2018
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Last Update Date | 10/31/2025
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Provider Practice Location Address
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Address Line | 11109 PARKVIEW PLAZA DR
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City | FORT WAYNE
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State | IN
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Zip | 46845
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Country | US
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Telephone | 260-425-6030
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Fax | 260-425-6028
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Provider Business Mailing Address
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Address Line | 3702 NEW VISION DR BLDG B
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City | FORT WAYNE
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State | IN
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Zip | 46845-1703
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Country | US
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Telephone |
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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 | 367H00000X
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Taxonomy Name | Anesthesiologist Assistant
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License Number | 75000046A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 367H00000X
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Taxonomy Name | Anesthesiologist Assistant
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License Number | AA484
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 367H00000X
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Taxonomy Name | Anesthesiologist Assistant
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License Number |
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License Number State |
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