Provider Demographics
NPI:1427053685
Name:VANDYKE, TAMARA (PA-C)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:VANDYKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6490 S. MCCARRAN BLVD
Mailing Address - Street 2:STE D-38
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509
Mailing Address - Country:US
Mailing Address - Phone:775-829-1212
Mailing Address - Fax:775-829-1179
Practice Address - Street 1:6490 S. MCCARRAN BLVD
Practice Address - Street 2:STE D-38
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509
Practice Address - Country:US
Practice Address - Phone:775-829-1212
Practice Address - Fax:775-829-1179
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV805207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV38310Medicare ID - Type Unspecified
Q03970Medicare UPIN