Provider Demographics
NPI:1225056401
Name:VANDERVOORT, PAUL G (CRNA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:G
Last Name:VANDERVOORT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1238 COX RD
Mailing Address - Street 2:
Mailing Address - City:RYDAL
Mailing Address - State:PA
Mailing Address - Zip Code:19046-1207
Mailing Address - Country:US
Mailing Address - Phone:917-575-2151
Mailing Address - Fax:
Practice Address - Street 1:3998 RED LION RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1436
Practice Address - Country:US
Practice Address - Phone:215-612-4000
Practice Address - Fax:215-807-8235
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN546215367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3056444OtherAETNA CONTRACT
PA096505RDBMedicare PIN
PA3056444OtherAETNA CONTRACT