Provider Demographics
NPI:1932445954
Name:VANDERWAERDEN, YENNY ASTRID-ANGEL (MD)
Entity Type:Individual
Prefix:DR
First Name:YENNY
Middle Name:ASTRID-ANGEL
Last Name:VANDERWAERDEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:980-488-4900
Mailing Address - Fax:980-488-4905
Practice Address - Street 1:10905 PROVIDENCE RD W
Practice Address - Street 2:SUITE G200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-1538
Practice Address - Country:US
Practice Address - Phone:980-488-4900
Practice Address - Fax:980-488-4905
Is Sole Proprietor?:No
Enumeration Date:2012-12-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36309207R00000X, 208M00000X
NC2016-01955208M00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC363092Medicaid
SCP01364174OtherRAILROAD MEDICARE
SC363092Medicaid
SCSC20489068Medicare PIN