Provider Demographics
NPI:1235551409
Name:MOODY, DERICK W (PA)
Entity Type:Individual
Prefix:
First Name:DERICK
Middle Name:W
Last Name:MOODY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:672 W 400 S
Mailing Address - Street 2:STE 201
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-3170
Mailing Address - Country:US
Mailing Address - Phone:801-812-4673
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:672 W 400 S STE 201
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-3170
Practice Address - Country:US
Practice Address - Phone:801-369-8989
Practice Address - Fax:801-704-9741
Is Sole Proprietor?:No
Enumeration Date:2014-01-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8820342-1206364SP0808X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant