Provider Demographics
NPI:1902946759
Name:VANVOOREN, MARIANNE EVA (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:EVA
Last Name:VANVOOREN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARIANNE
Other - Middle Name:EVA
Other - Last Name:HUSUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4376 7TH ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6867
Mailing Address - Country:US
Mailing Address - Phone:309-762-0777
Mailing Address - Fax:309-762-0077
Practice Address - Street 1:4376 7TH ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6867
Practice Address - Country:US
Practice Address - Phone:309-762-0777
Practice Address - Fax:309-762-0077
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001550363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085001550OtherILLINOIS LICENSE