Provider Demographics
NPI:1376595959
Name:VANNORDEN, MARK ETHAN (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ETHAN
Last Name:VANNORDEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LARNED
Mailing Address - State:KS
Mailing Address - Zip Code:67550-2602
Mailing Address - Country:US
Mailing Address - Phone:620-285-6041
Mailing Address - Fax:620-285-6194
Practice Address - Street 1:200 E 8TH ST
Practice Address - Street 2:
Practice Address - City:LARNED
Practice Address - State:KS
Practice Address - Zip Code:67550-2602
Practice Address - Country:US
Practice Address - Phone:620-285-6041
Practice Address - Fax:620-285-6194
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0530418207P00000X
KS05-30418207PE0004X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200252510CMedicaid
KS107025OtherBLUE SHIELD
KS200252510FMedicaid
KSI03148Medicare UPIN
KS200252510CMedicaid