Provider Demographics
NPI:1982176947
Name:VANDIVER, ABRAHAM ALEJANDRO (FNP)
Entity Type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:ALEJANDRO
Last Name:VANDIVER
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2340 MARLENE AVE
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-8833
Mailing Address - Country:US
Mailing Address - Phone:760-960-2663
Mailing Address - Fax:
Practice Address - Street 1:1600 S IMPERIAL AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4242
Practice Address - Country:US
Practice Address - Phone:760-339-2802
Practice Address - Fax:760-339-2829
Is Sole Proprietor?:No
Enumeration Date:2018-12-31
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA820909163W00000X
CA95011167363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse