Individual
R KENT VANDERGRIFF
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
ACNP
Contact information
Practice address
800 E DAWSON ST, TYLER, TX 75701-2036
(903) 525-1914
Mailing address
PO BOX 841656, DALLAS, TX 75284-1656
(903) 531-5000
Taxonomy
Speciality
Code
Description
License number
State
363LC0200X
Critical Care Medicine Nurse Practitioner
Primary
631043
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
280002101
—
TX
01
—
835N41
BCBS
TX
01
—
TIN PLUS 042
TRICARE
TX
Enumeration date
12/08/2010
Last updated
10/14/2014
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