Provider Demographics
NPI:1891769600
Name:VANDOLAH, MARK E (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:VANDOLAH
Suffix:
Gender:M
Credentials:CRNA
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 1330
Mailing Address - Street 2:7 VANDOLAH ROAD
Mailing Address - City:THREE FORKS
Mailing Address - State:MT
Mailing Address - Zip Code:59752-1330
Mailing Address - Country:US
Mailing Address - Phone:406-285-6588
Mailing Address - Fax:406-285-9012
Practice Address - Street 1:7 VANDOLAH ROAD
Practice Address - Street 2:
Practice Address - City:THREE FORKS
Practice Address - State:MT
Practice Address - Zip Code:59752-1330
Practice Address - Country:US
Practice Address - Phone:406-285-6588
Practice Address - Fax:406-285-9012
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-16
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN14372367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4308525Medicaid
MT000006666Medicare PIN