Provider Demographics
NPI:1215545934
Name:WHALEN, DEREK (PA-C)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:WHALEN
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 1:4705 UNIVERSITY DR BLDG 700
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-3489
Mailing Address - Country:US
Mailing Address - Phone:919-237-1337
Mailing Address - Fax:919-237-1625
Practice Address - Street 1:1621 PROVIDENCE RD S STE 370
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-8331
Practice Address - Country:US
Practice Address - Phone:704-520-7089
Practice Address - Fax:704-520-7099
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
PAMAO61728363A00000X
PAMA061728363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant