Provider Demographics
NPI:1093755704
Name:DERRYBERRY, HASKELL RAY (FNP)
Entity Type:Individual
Prefix:
First Name:HASKELL
Middle Name:RAY
Last Name:DERRYBERRY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 PALUXY RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-5603
Mailing Address - Country:US
Mailing Address - Phone:817-579-1642
Mailing Address - Fax:
Practice Address - Street 1:1322 PALUXY RD
Practice Address - Street 2:SUITE #2
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-5603
Practice Address - Country:US
Practice Address - Phone:817-579-1642
Practice Address - Fax:817-579-9926
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX582138363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
S76610Medicare UPIN