Provider Demographics
NPI:1255485561
Name:VANDENDRIES, BRIAN P (NP)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:P
Last Name:VANDENDRIES
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-706-7500
Mailing Address - Fax:208-706-7501
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:SUITE 2213
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6351
Practice Address - Country:US
Practice Address - Phone:208-706-5447
Practice Address - Fax:208-706-5448
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-637363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20001280Medicare PIN