Provider Demographics
NPI:1295856532
Name:VANDERVORT, HARRY ERNEST III (FNP)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:ERNEST
Last Name:VANDERVORT
Suffix:III
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:DUKE
Other - Middle Name:
Other - Last Name:VANDERVORT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4000 E 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-0640
Mailing Address - Country:US
Mailing Address - Phone:541-463-5665
Mailing Address - Fax:541-463-4164
Practice Address - Street 1:4000 E 30TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97405-0640
Practice Address - Country:US
Practice Address - Phone:541-463-5665
Practice Address - Fax:541-463-4164
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR88-000106363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR88-000106OtherNURSE PRACTITIONER LICENS
MV0162189OtherDEA NUMBER
501434Medicare UPIN