Provider Demographics
NPI:1922436278
Name:VANDERFORD, JULIE MICHELLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:MICHELLE
Last Name:VANDERFORD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:MICHELLE
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVDIER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 N SENATE BLVD
Practice Address - Street 2:SUITE 4000
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1228
Practice Address - Country:US
Practice Address - Phone:317-962-2500
Practice Address - Fax:317-962-2515
Is Sole Proprietor?:No
Enumeration Date:2013-10-24
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001596A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN264430173Medicare PIN