Provider Demographics
NPI:1134514490
Name:VANDOKKUMBURG, KEVIN (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:VANDOKKUMBURG
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 1:2144 E PARIS AVE SE STE 240
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6117
Mailing Address - Country:US
Mailing Address - Phone:616-949-8945
Mailing Address - Fax:616-949-1115
Practice Address - Street 1:2144 E PARIS AVE SE STE 240
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6117
Practice Address - Country:US
Practice Address - Phone:616-949-8945
Practice Address - Fax:616-949-1115
Is Sole Proprietor?:No
Enumeration Date:2015-04-03
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007350363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1134514490Medicaid
MIM51600026Medicare PIN