Provider Demographics
NPI:1225758824
Name:VANDERWEIDE, MARK LEROY (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LEROY
Last Name:VANDERWEIDE
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 1:854 DORROLL ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-4209
Mailing Address - Country:US
Mailing Address - Phone:616-914-6532
Mailing Address - Fax:
Practice Address - Street 1:14700 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-1999
Practice Address - Country:US
Practice Address - Phone:231-547-4024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-01
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704293836367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered