Provider Demographics
NPI:1477155364
Name:VANDER SYS, ASHLEY NICOLE
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NICOLE
Last Name:VANDER SYS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:NICOLE
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 6369
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59604-6369
Mailing Address - Country:US
Mailing Address - Phone:406-447-2823
Mailing Address - Fax:406-447-2825
Practice Address - Street 1:3330 PTARMIGAN LN
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59602-0521
Practice Address - Country:US
Practice Address - Phone:406-457-4180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-15
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT103616363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAVANDEAN167ODOtherDRIVER'S LICENSE