Basic Information
| Provider Information | |||||||||
| NPI: | 1225056401 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDERVOORT | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | G. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1238 COX RD | ||||||||
| Address2: | |||||||||
| City: | RYDAL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190461207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9175752151 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3998 RED LION RD | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191141436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156124000 | ||||||||
| FaxNumber: | 2158078235 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 07/28/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN546215 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3056444 | 01 | PA | AETNA CONTRACT | OTHER |