Basic Information
| Provider Information | |||||||||
| NPI: | 1063515419 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAN-NURDEN | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 LITTLE MOUNTAIN LN | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982748752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604166735 | ||||||||
| FaxNumber: | 3604246954 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 LITTLE MOUNTAIN LN | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982748752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604166735 | ||||||||
| FaxNumber: | 3604246954 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 12/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OD00003472WA | WA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | MN2722 | MN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1547620 | 01 | MN | AMERICA'S PPO | OTHER | 183M0VA | 01 | MN | BCBS/MN | OTHER | MN2722 | 01 | MN | EYEMED | OTHER | 108405400 | 05 | MN | MEDICAID | 2201774 | 01 | MN | MEDICA/UNITED HEALTH CARE | OTHER |