Provider Demographics
NPI:1740545227
Name:IRVING, VANNA KAY (MD)
Entity type:Individual
Prefix:
First Name:VANNA
Middle Name:KAY
Last Name:IRVING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VANNA
Other - Middle Name:KAY
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:550 W HWY 50
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-2238
Mailing Address - Country:US
Mailing Address - Phone:195-302-0227
Mailing Address - Fax:719-539-2375
Practice Address - Street 1:550 W HWY 50
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-2238
Practice Address - Country:US
Practice Address - Phone:719-530-2022
Practice Address - Fax:719-539-2375
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-01300207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program