Provider Demographics
NPI:1851335905
Name:VANDER MATEN, JON (PA)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:VANDER MATEN
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 1:100 MAC LANE
Mailing Address - Street 2:
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501-0758
Mailing Address - Country:US
Mailing Address - Phone:605-224-5901
Mailing Address - Fax:605-945-9295
Practice Address - Street 1:100 MAC LANE
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-0758
Practice Address - Country:US
Practice Address - Phone:605-224-5901
Practice Address - Fax:605-945-9295
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0052363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDR02481Medicare UPIN