Provider Demographics
NPI:1952317141
Name:VANDERMEULEN, STEPHANE P (PA C)
Entity Type:Individual
Prefix:MS
First Name:STEPHANE
Middle Name:P
Last Name:VANDERMEULEN
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:MS
Other - First Name:STEPHANE
Other - Middle Name:P
Other - Last Name:MATHIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA C
Mailing Address - Street 1:2725 SOUTH 144TH STREET
Mailing Address - Street 2:SUITE 212
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144
Mailing Address - Country:US
Mailing Address - Phone:402-637-0800
Mailing Address - Fax:402-637-0852
Practice Address - Street 1:2725 SOUTH 144TH STREET
Practice Address - Street 2:SUITE 212
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144
Practice Address - Country:US
Practice Address - Phone:402-637-0800
Practice Address - Fax:402-637-0852
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE624363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE38626OtherBCBS OF NE
R64095Medicare UPIN
NE275208Medicare PIN