Provider Demographics
NPI:1346375367
Name:EDDIE, DEREK (PA-C)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:EDDIE
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 1:560 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4073
Mailing Address - Country:US
Mailing Address - Phone:208-234-1960
Mailing Address - Fax:208-233-5033
Practice Address - Street 1:560 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4073
Practice Address - Country:US
Practice Address - Phone:208-234-1960
Practice Address - Fax:208-233-5033
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-662363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical