Provider Demographics
NPI:1497132112
Name:VAN DER WEG, IAN
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:VAN DER WEG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 SW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-4209
Mailing Address - Country:US
Mailing Address - Phone:316-288-1583
Mailing Address - Fax:
Practice Address - Street 1:307 LAKEWOOD DR
Practice Address - Street 2:
Practice Address - City:NORTH NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67117-8075
Practice Address - Country:US
Practice Address - Phone:316-288-1583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-01
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS103495163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse