Provider Demographics
NPI:1467850768
Name:VANDAELE, SARAH LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:LYNN
Last Name:VANDAELE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:LYNN
Other - Last Name:SISSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2799 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2608
Mailing Address - Country:US
Mailing Address - Phone:800-436-7936
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:800-436-7936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-18
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
MI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601008594OtherMICHIGAN STATE LICENSE