Provider Demographics
NPI:1629059126
Name:VANDIVER, JOHNNY RAY (PA)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:RAY
Last Name:VANDIVER
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:PO BOX 33154
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99803-3154
Mailing Address - Country:US
Mailing Address - Phone:907-687-8224
Mailing Address - Fax:
Practice Address - Street 1:12233 24TH STREET
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS MCHORD
Practice Address - State:WA
Practice Address - Zip Code:98433
Practice Address - Country:US
Practice Address - Phone:253-477-5734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant