Provider Demographics
NPI:1194951905
Name:VANDIEN, MARK R (RPA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:VANDIEN
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Gender:M
Credentials:RPA
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Mailing Address - Street 1:100 PARK STREET
Mailing Address - Street 2:GLENS FALLS HOSPITAL - CREDENTIALING
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4413
Mailing Address - Country:US
Mailing Address - Phone:518-926-5924
Mailing Address - Fax:518-926-6983
Practice Address - Street 1:6 HEARTS WAY
Practice Address - Street 2:ADIRONDACK CARDIOLOGY
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-5925
Practice Address - Country:US
Practice Address - Phone:518-792-1233
Practice Address - Fax:518-792-6854
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2021-07-29
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Provider Licenses
StateLicense IDTaxonomies
NY013357363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03139475Medicaid
NY400060080Medicare PIN