Basic Information
| Provider Information | |||||||||
| NPI: | 1417424144 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDERBUR | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | JOHN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 MAIN ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | SPEEDWAY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462246977 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1011 MAIN ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462246977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179579150 | ||||||||
| FaxNumber: | 3179579965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2018 | ||||||||
| LastUpdateDate: | 04/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 28201828A | IN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 71008664A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.