Provider Demographics
NPI:1124544150
Name:NANCE, DEREK N (PAC)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:N
Last Name:NANCE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 LONE OAK RD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-7901
Mailing Address - Country:US
Mailing Address - Phone:270-444-2150
Mailing Address - Fax:
Practice Address - Street 1:1530 LONE OAK RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7901
Practice Address - Country:US
Practice Address - Phone:270-444-2150
Practice Address - Fax:270-444-2985
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2298363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant