Provider Demographics
NPI:1710342134
Name:VANDENBOSCH, EVAN REID (PA-C)
Entity Type:Individual
Prefix:MR
First Name:EVAN
Middle Name:REID
Last Name:VANDENBOSCH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36622 5 MILE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-1900
Mailing Address - Country:US
Mailing Address - Phone:734-542-0200
Mailing Address - Fax:
Practice Address - Street 1:36622 5 MILE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1900
Practice Address - Country:US
Practice Address - Phone:734-542-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-30
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007644363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical