Provider Demographics
NPI:1124039201
Name:VANDEVENDER, GINA (PA)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:
Last Name:VANDEVENDER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 HOSPITAL DR
Mailing Address - Street 2:STE 115
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-4600
Mailing Address - Country:US
Mailing Address - Phone:409-838-4533
Mailing Address - Fax:409-833-1616
Practice Address - Street 1:810 HOSPITAL DR
Practice Address - Street 2:STE 115
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-4600
Practice Address - Country:US
Practice Address - Phone:409-838-4533
Practice Address - Fax:409-833-1616
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00363363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J7840Medicare PIN
TXQ40954Medicare UPIN