Provider Demographics
NPI:1265483069
Name:ROPER, DEREK THOMAS (PA)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:THOMAS
Last Name:ROPER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1315
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29641-1315
Mailing Address - Country:US
Mailing Address - Phone:864-635-0376
Mailing Address - Fax:864-442-6848
Practice Address - Street 1:115 BRUSHY CREEK RD
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29642-1120
Practice Address - Country:US
Practice Address - Phone:864-635-0376
Practice Address - Fax:864-442-6848
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA849363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0274PAMedicaid
SC5737Medicare ID - Type UnspecifiedMEDICARE GROUP
SCAA02945737Medicare ID - Type Unspecified