MEDICARE: JACOB MATTHEW VONDEBUR PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	085011450	IL
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1235023045
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB MATTHEW VONDEBUR PA-C

Provider Business Mailing Address
First Line	:	2303 HUNTINGTON RD
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62703-5009
Country	:	US
Telephone Number	:	217-303-4991
Fax Number	:

Provider Business Practice Location Address
First Line	:	2303 HUNTINGTON RD
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62703-5009
Country	:	US
Telephone Number	:	217-303-4991
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2025
Last Update Date	:	07/25/2025

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