Provider Demographics
NPI:1003428707
Name:SISK, DEREK JASON (APRN)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:JASON
Last Name:SISK
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3554 65TH AVENUE CIR E
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-4116
Mailing Address - Country:US
Mailing Address - Phone:941-250-4279
Mailing Address - Fax:
Practice Address - Street 1:3554 65TH AVENUE CIR E
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-4116
Practice Address - Country:US
Practice Address - Phone:941-250-4279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11008173363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner