Provider Demographics
NPI:1104117431
Name:VANDAAM, PERCIVAL CHRISTOPHER (MPAS, PA-C)
Entity type:Individual
Prefix:
First Name:PERCIVAL
Middle Name:CHRISTOPHER
Last Name:VANDAAM
Suffix:
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:CAMBIRDGE HEALTH ALLIANCE.
Mailing Address - Street 2:1493 CAMBRIDGE STREET
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139
Mailing Address - Country:US
Mailing Address - Phone:617-665-1000
Mailing Address - Fax:
Practice Address - Street 1:103 GARLAND STREET
Practice Address - Street 2:WHIDDEN HOSPITAL EMERGENCY DEPARTMENT
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149
Practice Address - Country:US
Practice Address - Phone:617-665-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MAPA4149363A00000X
RIPA00579363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant