Provider Demographics
NPI:1245579408
Name:KORDENBROCK, DEREK BRENT (NP)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:BRENT
Last Name:KORDENBROCK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:815 N CENTRAL AVE STE C
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-5873
Mailing Address - Country:US
Mailing Address - Phone:541-734-9030
Mailing Address - Fax:541-734-9885
Practice Address - Street 1:1345 CENTER DR UNIT A
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-7945
Practice Address - Country:US
Practice Address - Phone:541-734-9030
Practice Address - Fax:541-734-9885
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22446363LA2200X, 363LX0106X
OR201604376NP-PP363LX0106X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health