Provider Demographics
NPI:1568488716
Name:VANWOERKOM, JON S (PA)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:S
Last Name:VANWOERKOM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8433 HARCOURT RD
Mailing Address - Street 2:STE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2193
Mailing Address - Country:US
Mailing Address - Phone:317-583-7600
Mailing Address - Fax:317-583-7601
Practice Address - Street 1:8433 HARCOURT RD
Practice Address - Street 2:STE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2193
Practice Address - Country:US
Practice Address - Phone:317-583-7600
Practice Address - Fax:317-583-7601
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000482A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
970018927OtherRAILROAD MEDICARE PIN
000000374068OtherBCBS PIN
970018927OtherRAILROAD MEDICARE PIN
179190MMedicare PIN
000000374068OtherBCBS PIN