Provider Demographics
NPI:1215793989
Name:VANDAM, NINA
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:VANDAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NINA
Other - Middle Name:NING
Other - Last Name:SU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6935 ALIANTE PARKWAY
Mailing Address - Street 2:#104-240
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084
Mailing Address - Country:US
Mailing Address - Phone:858-361-9860
Mailing Address - Fax:
Practice Address - Street 1:6935 ALIANTE PARKWAY
Practice Address - Street 2:#104-240
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89084
Practice Address - Country:US
Practice Address - Phone:858-361-9860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35511207NI0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology