Provider Demographics
NPI:1316470768
Name:VANGIESON, ROBERT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:VANGIESON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51135 HANFORD RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-4605
Mailing Address - Country:US
Mailing Address - Phone:734-545-4106
Mailing Address - Fax:
Practice Address - Street 1:51135 HANFORD RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-4605
Practice Address - Country:US
Practice Address - Phone:734-545-4106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIM735761343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)