Provider Demographics
NPI:1407886203
Name:VANDEVENDER, KENT WAYNE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KENT
Middle Name:WAYNE
Last Name:VANDEVENDER
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:PO BOX 2500
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:VA
Mailing Address - Zip Code:24402-2500
Mailing Address - Country:US
Mailing Address - Phone:540-332-8220
Mailing Address - Fax:540-332-8385
Practice Address - Street 1:103 VALLEY CENTER DR
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:VA
Practice Address - Zip Code:24401-5080
Practice Address - Country:US
Practice Address - Phone:540-332-8220
Practice Address - Fax:540-332-8385
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV621363AM0700X
VA0110002674363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810026229Medicaid
WV3810026229Medicaid
WVWV2885AMedicare PIN
WVP12025Medicare UPIN