Provider Demographics
NPI:1124214358
Name:VANDERVORT, MARK (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:VANDERVORT
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 1:4280 MERIDIAN ST
Mailing Address - Street 2:STE 120
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-6464
Mailing Address - Country:US
Mailing Address - Phone:360-734-4300
Mailing Address - Fax:
Practice Address - Street 1:4280 MERIDIAN ST
Practice Address - Street 2:STE 120
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-6464
Practice Address - Country:US
Practice Address - Phone:360-734-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60055369363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant