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General NPI Number Information
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NPI Number | 1942520507
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Entity Type | Individual
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Provider Name | LARRY WAYNE VANDERMOLEN PA-C
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Gender | Male
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Dates
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Enumeration Date | 06/07/2010
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Last Update Date | 07/20/2010
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Provider Practice Location Address
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Address Line | 2626 E COVENANTER CT
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City | BLOOMINGTON
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State | IN
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Zip | 47401-5408
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Country | US
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Telephone | 812-345-5556
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Fax |
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Provider Business Mailing Address
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Address Line | 2626 E COVENANTER CT
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City | BLOOMINGTON
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State | IN
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Zip | 47401-5408
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 99042551A
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License Number State | IN
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