Basic Information
Provider Information | |||||||||
NPI: | 1659570554 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VANDERWIELEN | ||||||||
FirstName: | JAMIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PETERS | ||||||||
OtherFirstName: | JAMIE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 7112 | ||||||||
Address2: | DPT 31 | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462077112 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3178023151 | ||||||||
FaxNumber: | 3178700499 | ||||||||
Practice Location | |||||||||
Address1: | 1600 ALBANY ST | ||||||||
Address2: |   | ||||||||
City: | BEECH GROVE | ||||||||
State: | IN | ||||||||
PostalCode: | 461071541 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3177838148 | ||||||||
FaxNumber: | 3178700499 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2007 | ||||||||
LastUpdateDate: | 09/16/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/16/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10000946A | IN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AM0700X | 99027746A | IN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.