Provider Demographics
NPI:1528343613
Name:VAN DYNE, DESIREE ETTALEE (PA)
Entity type:Individual
Prefix:MS
First Name:DESIREE
Middle Name:ETTALEE
Last Name:VAN DYNE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 OLENTANGY RIVER RD STE 2010
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-3998
Mailing Address - Country:US
Mailing Address - Phone:614-566-5000
Mailing Address - Fax:
Practice Address - Street 1:3535 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3998
Practice Address - Country:US
Practice Address - Phone:614-566-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC224363A00000X
KYPA3049363A00000X
OH50.003418RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100835360Medicaid
IN300067576Medicaid