1457758815 NPI number — JESSICA D VAN WULVEN PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457758815 NPI number — JESSICA D VAN WULVEN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN WULVEN
Provider First Name:
JESSICA
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROWLEY
Provider Other First Name:
JESSICA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457758815
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3765 E. BLUE LUPINE DR. STE D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASILLA
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-707-1671
Provider Business Mailing Address Fax Number:
907-707-1675

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3765 E. BLUE LUPINE DR. STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASILLA
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-707-1671
Provider Business Practice Location Address Fax Number:
907-707-1675
Provider Enumeration Date:
12/01/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  2365 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PADA1218 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1648921 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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