Provider Demographics
NPI:1083754287
Name:VANFOSSEN, ERIC DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:DAVID
Last Name:VANFOSSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21039 GEYER DR
Mailing Address - Street 2:
Mailing Address - City:WAPAKONETA
Mailing Address - State:OH
Mailing Address - Zip Code:45895-8815
Mailing Address - Country:US
Mailing Address - Phone:937-596-5386
Mailing Address - Fax:
Practice Address - Street 1:1205 FAIRINGTON DR
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-8144
Practice Address - Country:US
Practice Address - Phone:937-492-8431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0805363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical