Provider Demographics
NPI:1083924500
Name:RIAS, DERICK WAYNE (RPAC)
Entity Type:Individual
Prefix:MR
First Name:DERICK
Middle Name:WAYNE
Last Name:RIAS
Suffix:
Gender:M
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18361 ELMIRA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-1515
Mailing Address - Country:US
Mailing Address - Phone:718-454-3962
Mailing Address - Fax:
Practice Address - Street 1:18361 ELMIRA AVE
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-1515
Practice Address - Country:US
Practice Address - Phone:718-454-3962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002394363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant