Provider Demographics
NPI:1275589913
Name:VANDERLAAN, LEON (PA-C)
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:
Last Name:VANDERLAAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE MC-845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:1108 W STATE ST
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-9711
Practice Address - Country:US
Practice Address - Phone:269-948-3102
Practice Address - Fax:269-948-5891
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001241363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1104840529OtherBCBSM - BRONSON URGENT CARE
MIM20520086Medicare PIN
MIOM02830008Medicare PIN