Individual
MR. LARRY WAYNE VANDERMOLEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
2626 E COVENANTER CT, BLOOMINGTON, IN 47401-5408
(812) 345-5556
Mailing address
2626 E COVENANTER CT, BLOOMINGTON, IN 47401-5408
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
99042551A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10001177A
LICENSE
IN
Enumeration date
06/07/2010
Last updated
07/20/2010
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