Provider Demographics
NPI:1053190348
Name:VANDER WALL, DANE (ND)
Entity type:Individual
Prefix:
First Name:DANE
Middle Name:
Last Name:VANDER WALL
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9757 W ARNOLD RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-8210
Mailing Address - Country:US
Mailing Address - Phone:720-220-5331
Mailing Address - Fax:
Practice Address - Street 1:9757 W ARNOLD RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714-8210
Practice Address - Country:US
Practice Address - Phone:720-220-5331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty