Provider Demographics
NPI:1346310067
Name:VANFOSSEN, GREGORY (NP)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:VANFOSSEN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59342 OLD COUNTY ROAD 17
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46528-8421
Mailing Address - Country:US
Mailing Address - Phone:574-875-0687
Mailing Address - Fax:
Practice Address - Street 1:640 INDUSTRIAL PARKWAY
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-5414
Practice Address - Country:US
Practice Address - Phone:574-522-7203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001747A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S02784Medicare UPIN