Provider Demographics
NPI:1164756664
Name:WEST, DEREK M (ACNP-BC)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:M
Last Name:WEST
Suffix:
Gender:M
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 MARY ST STE 520
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-1682
Mailing Address - Country:US
Mailing Address - Phone:812-424-8231
Mailing Address - Fax:812-435-8794
Practice Address - Street 1:520 MARY ST STE 520
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-1682
Practice Address - Country:US
Practice Address - Phone:812-424-8231
Practice Address - Fax:812-435-8794
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003054A363LA2100X
IN71003054363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100101320Medicaid
IN71003054AOtherIN LICENSE
IN200975230Medicaid
IN000000637973OtherANTHEM
INP00905143OtherRAILROAD MEDICARE
IN200975230Medicaid