Provider Demographics
NPI:1578541470
Name:VANANROOY, MARK (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:VANANROOY
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Gender:M
Credentials:PA
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Mailing Address - Street 1:1235 NORTH MULFORD ROAD
Mailing Address - Street 2:SUITE 222
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3879
Mailing Address - Country:US
Mailing Address - Phone:815-397-8400
Mailing Address - Fax:815-229-0050
Practice Address - Street 1:1235 NORTH MULFORD ROAD
Practice Address - Street 2:SUITE 222
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3879
Practice Address - Country:US
Practice Address - Phone:815-397-8400
Practice Address - Fax:815-229-0050
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2024-12-11
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Provider Licenses
StateLicense IDTaxonomies
IL085001774363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207480 - K03438Medicare PIN
ILP63219Medicare UPIN