Provider Demographics
NPI:1760691851
Name:VANDERWAL, ECHO T (PA)
Entity Type:Individual
Prefix:
First Name:ECHO
Middle Name:T
Last Name:VANDERWAL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 N 2ND AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1565
Mailing Address - Country:US
Mailing Address - Phone:208-265-2242
Mailing Address - Fax:208-265-8214
Practice Address - Street 1:420 N 2ND AVE
Practice Address - Street 2:STE 100
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1565
Practice Address - Country:US
Practice Address - Phone:208-265-2242
Practice Address - Fax:208-265-8214
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA671363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant