Provider Demographics
NPI:1043490543
Name:ASSOCIATED VALLEY PROVIDERS PLLC
Entity Type:Organization
Organization Name:ASSOCIATED VALLEY PROVIDERS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:VANDERHEYDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-255-5111
Mailing Address - Street 1:4361 TALBOT RD S
Mailing Address - Street 2:SUITE 112
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-6226
Mailing Address - Country:US
Mailing Address - Phone:425-255-5111
Mailing Address - Fax:425-254-0985
Practice Address - Street 1:4361 TALBOT RD S
Practice Address - Street 2:SUITE 112
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-6226
Practice Address - Country:US
Practice Address - Phone:425-255-5111
Practice Address - Fax:425-254-0985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA207Q00000X, 207V00000X, 213ES0103X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7112634Medicaid
WA6225540001Medicare NSC
WAGAB29073Medicare UPIN