Basic Information
Provider Information | |||||||||
NPI: | 1013971340 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VANARSDALE | ||||||||
FirstName: | SHARON | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-BC, GNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 21990 HIGHWAY 62 | ||||||||
Address2: |   | ||||||||
City: | SHADY COVE | ||||||||
State: | OR | ||||||||
PostalCode: | 975399717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5418782022 | ||||||||
FaxNumber: | 5418781498 | ||||||||
Practice Location | |||||||||
Address1: | 21990 HIGHWAY 62 | ||||||||
Address2: |   | ||||||||
City: | SHADY COVE | ||||||||
State: | OR | ||||||||
PostalCode: | 975399717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5418782022 | ||||||||
FaxNumber: | 5418781498 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/13/2006 | ||||||||
LastUpdateDate: | 05/01/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 201710218RN | OR | N |   | Nursing Service Providers | Registered Nurse |   | 363LG0600X | 201710219NP-PP | OR | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LF0000X | 201710219NP-PP | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 424967313 | 05 | MO |   | MEDICAID |