Basic Information
Provider Information | |||||||||
NPI: | 1982176947 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VANDIVER | ||||||||
FirstName: | ABRAHAM | ||||||||
MiddleName: | ALEJANDRO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2340 MARLENE AVE | ||||||||
Address2: |   | ||||||||
City: | IMPERIAL | ||||||||
State: | CA | ||||||||
PostalCode: | 922518833 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7609602663 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1600 S IMPERIAL AVE | ||||||||
Address2: |   | ||||||||
City: | EL CENTRO | ||||||||
State: | CA | ||||||||
PostalCode: | 922434242 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7603392802 | ||||||||
FaxNumber: | 7603392829 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/31/2018 | ||||||||
LastUpdateDate: | 02/14/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 820909 | CA | N |   | Nursing Service Providers | Registered Nurse |   | 363LF0000X | 95011167 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.