Provider Demographics
NPI:1346284817
Name:VANDERVORT, ROYCE J (CRNA)
Entity Type:Individual
Prefix:
First Name:ROYCE
Middle Name:J
Last Name:VANDERVORT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4135 BOARDMAN CANFIELD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9803
Mailing Address - Country:US
Mailing Address - Phone:330-286-5330
Mailing Address - Fax:330-286-5396
Practice Address - Street 1:1307 FEDERAL ST
Practice Address - Street 2:SUITE 101
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15212-4705
Practice Address - Country:US
Practice Address - Phone:412-231-6550
Practice Address - Fax:412-231-6697
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2019-08-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OHRN239247367500000X
PARN536104367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
11929464OtherCAQH
PA0019763430008Medicaid
OH8232124OtherMEDICARE PTAN
PA074629TV6OtherMEDICARE PTAN
OH2418379Medicaid