Alex Chadwick Van Der Ham, PA

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

59204 Issued in CA

Practice address

26730 Towne Centre Dr Ste 204
Lake Forest, CA 92610-2842

Phone

(949) 380-1234

NPI assigned

Oct 21, 2019

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1571616000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1617840000000",
    "number": "1043853237",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "26730 TOWNE CENTRE DR STE 204",
            "city": "FOOTHILL RANCH",
            "state": "CA",
            "postal_code": "926102842",
            "telephone_number": "714-589-5123"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "26730 TOWNE CENTRE DR STE 204",
            "city": "LAKE FOREST",
            "state": "CA",
            "postal_code": "926102842",
            "telephone_number": "949-380-1234"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2575 Yorba Linda Blvd",
            "address_purpose": "LOCATION",
            "city": "Fullerton",
            "state": "CA",
            "postal_code": "928311699",
            "country_code": "US",
            "telephone_number": "714-589-5123",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "VAN DER HAM",
        "first_name": "ALEX",
        "middle_name": "CHADWICK",
        "credential": "PA",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2019-10-21",
        "last_updated": "2021-04-08",
        "certification_date": "2021-04-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Physician Assistant",
            "state": "CA",
            "license": "59204",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Physician Assistant in Lake Forest, CA
• Providers in Lake Forest, CA by specialty
• Physician Assistant in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 8, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.