Provider Demographics
NPI:1629035142
Name:VANDERHEE, JOHN ROBERT (PA-C, MPAS)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ROBERT
Last Name:VANDERHEE
Suffix:
Gender:M
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4604 BUTLER AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4258
Mailing Address - Country:US
Mailing Address - Phone:505-922-6462
Mailing Address - Fax:
Practice Address - Street 1:707 PASEO DE PERALTA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1922
Practice Address - Country:US
Practice Address - Phone:505-989-8707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2003-0027363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P98025Medicare UPIN