Provider Demographics
NPI:1174697296
Name:VANDERGAAG, ELIZABETH A (ARNP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:VANDERGAAG
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17198 ST LUKES WAY STE 600
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77384-8017
Mailing Address - Country:US
Mailing Address - Phone:936-266-2450
Mailing Address - Fax:936-266-8602
Practice Address - Street 1:625 9TH AVENUE
Practice Address - Street 2:STE 210
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2465
Practice Address - Country:US
Practice Address - Phone:360-501-3400
Practice Address - Fax:360-423-6862
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00156835163W00000X
WAAP30007439363L00000X
TXAP127186363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0229642OtherLABOR AND INDUSTRIES
WA9651027Medicaid
WA8870823Medicare PIN
WA0229642OtherLABOR AND INDUSTRIES