Provider Demographics
NPI:1073685285
Name:HENNESSY, DEREK (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:
Last Name:HENNESSY
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 1:322 W NORTH RIVER DR
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-3208
Mailing Address - Country:US
Mailing Address - Phone:509-276-5005
Mailing Address - Fax:509-276-7785
Practice Address - Street 1:322 W NORTH RIVER DR
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-3208
Practice Address - Country:US
Practice Address - Phone:509-276-5005
Practice Address - Fax:509-276-7785
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004720363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q74229Medicare UPIN