Provider Demographics
NPI:1144535220
Name:VANDERBECK, KENNETH J (PA-C)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:J
Last Name:VANDERBECK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8765 AERO DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123
Mailing Address - Country:US
Mailing Address - Phone:858-541-0181
Mailing Address - Fax:858-430-0919
Practice Address - Street 1:23181 VERDUGO DR STE 103A
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1313
Practice Address - Country:US
Practice Address - Phone:949-366-1053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105536363A00000X
CAPA21190363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant