Provider Demographics
NPI:1043853237
Name:VAN DER HAM, ALEX CHADWICK (PA)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:CHADWICK
Last Name:VAN DER HAM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26730 TOWNE CENTRE DR STE 204
Mailing Address - Street 2:
Mailing Address - City:FOOTHILL RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92610-2842
Mailing Address - Country:US
Mailing Address - Phone:714-589-5123
Mailing Address - Fax:
Practice Address - Street 1:26730 TOWNE CENTRE DR STE 204
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92610-2842
Practice Address - Country:US
Practice Address - Phone:949-380-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-21
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA59204363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty