Provider Demographics
NPI:1255305934
Name:VANDERLAAN, NICOLE DUMAS (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DUMAS
Last Name:VANDERLAAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:DUMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1550 BARKLEY CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-4539
Mailing Address - Country:US
Mailing Address - Phone:239-938-2000
Mailing Address - Fax:239-278-0404
Practice Address - Street 1:1550 BARKLEY CIR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-4539
Practice Address - Country:US
Practice Address - Phone:239-938-2000
Practice Address - Fax:239-278-0404
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002686363A00000X
FLPA9105000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P65250Medicare UPIN
N48650034Medicare PIN