Provider Demographics
NPI:1124405824
Name:VANDERPAN, MCKYNSAY DAY (MS, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:MCKYNSAY
Middle Name:DAY
Last Name:VANDERPAN
Suffix:
Gender:F
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2751 2ND AVE N STOP 9013
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58202-9013
Mailing Address - Country:US
Mailing Address - Phone:701-777-6147
Mailing Address - Fax:701-777-2536
Practice Address - Street 1:2751 2ND AVE N STOP 9013
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58202-9013
Practice Address - Country:US
Practice Address - Phone:701-777-6147
Practice Address - Fax:701-777-2536
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-01
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND293042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer