Basic Information
| Provider Information | |||||||||
| NPI: | 1952317141 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDERMEULEN | ||||||||
| FirstName: | STEPHANE | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MATHIS | ||||||||
| OtherFirstName: | STEPHANE | ||||||||
| OtherMiddleName: | P | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2725 SOUTH 144TH STREET | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4026370800 | ||||||||
| FaxNumber: | 4026370852 | ||||||||
| Practice Location | |||||||||
| Address1: | 2725 SOUTH 144TH STREET | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4026370800 | ||||||||
| FaxNumber: | 4026370852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 03/12/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 624 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 38626 | 01 | NE | BCBS OF NE | OTHER |