Provider Demographics
NPI:1144564949
Name:VANDERGON, MILDRED MARGARET (PT)
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:MARGARET
Last Name:VANDERGON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MEG
Other - Middle Name:
Other - Last Name:VANDERGON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:10620 LONE TREE DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-6924
Mailing Address - Country:US
Mailing Address - Phone:907-346-4509
Mailing Address - Fax:
Practice Address - Street 1:12103 HORSESHOE DR
Practice Address - Street 2:SUITE B
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7547
Practice Address - Country:US
Practice Address - Phone:907-696-3657
Practice Address - Fax:907-622-3657
Is Sole Proprietor?:No
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1001225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist