Provider Demographics
NPI:1922041789
Name:VANDERWEL, BRENDA (PA-C)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:VANDERWEL
Suffix:
Gender:F
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 1:9480 BRIAR VILLAGE PT
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7922
Mailing Address - Country:US
Mailing Address - Phone:719-278-3627
Mailing Address - Fax:719-623-2101
Practice Address - Street 1:9480 BRIAR VILLAGE PT
Practice Address - Street 2:SUITE 200
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7922
Practice Address - Country:US
Practice Address - Phone:719-278-3627
Practice Address - Fax:719-623-2101
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO352363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COJ50071Medicare ID - Type Unspecified
COS50244Medicare UPIN