Individual
DEREK DANIEL VANDERBURG
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
703 S AMERICANA BLVD STE 120, BOISE, ID 83702-6754
(208) 706-2663
Mailing address
190 E BANNOCK ST, BOISE, ID 83712-6241
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
11684
MN
363A00000X
Physician Assistant
Primary
PA-1908
ID
Other
Enumeration date
07/03/2014
Last updated
11/08/2022
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