Provider Demographics
NPI:1457567851
Name:VANDEKIEFT, DAVID K (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:K
Last Name:VANDEKIEFT
Suffix:
Gender:M
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 1:419 S CORAL ST
Mailing Address - Street 2:
Mailing Address - City:KALKASKA
Mailing Address - State:MI
Mailing Address - Zip Code:49646-2503
Mailing Address - Country:US
Mailing Address - Phone:231-258-7500
Mailing Address - Fax:231-258-7527
Practice Address - Street 1:419 S CORAL ST
Practice Address - Street 2:
Practice Address - City:KALKASKA
Practice Address - State:MI
Practice Address - Zip Code:49646-2503
Practice Address - Country:US
Practice Address - Phone:231-258-7500
Practice Address - Fax:231-258-7527
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT20768363A00000X
WY183363A00000X
MI5601004449363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1457567851Medicaid
MTM011002915OtherMEDICARE PTAN
ID1457567851Medicaid
MIB86032030Medicare PIN
MIP58153Medicare UPIN