Provider Demographics
NPI:1851686414
Name:VANDERWOUDE, IAN (PA-C, MSPAS)
Entity Type:Individual
Prefix:MR
First Name:IAN
Middle Name:
Last Name:VANDERWOUDE
Suffix:
Gender:M
Credentials:PA-C, MSPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9210 GOLF COURSE RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5891
Mailing Address - Country:US
Mailing Address - Phone:505-899-3933
Mailing Address - Fax:
Practice Address - Street 1:9210 GOLF COURSE RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5891
Practice Address - Country:US
Practice Address - Phone:505-899-3933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-12
Last Update Date:2011-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2011-0015363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical