Individual
JOHNNY RAY VANDIVER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
12233 24TH STREET, JOINT BASE LEWIS MCHORD, WA 98433
(253) 477-5734
Mailing address
PO BOX 33154, JUNEAU, AK 99803-3154
(907) 687-8224
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
—
—
Other
Enumeration date
11/10/2005
Last updated
11/07/2012
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