Provider Demographics
NPI:1396217485
Name:STACKPOLE, DERICK
Entity Type:Individual
Prefix:
First Name:DERICK
Middle Name:
Last Name:STACKPOLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4035 ELECTRIC RD STE A
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-8449
Mailing Address - Country:US
Mailing Address - Phone:540-772-8670
Mailing Address - Fax:
Practice Address - Street 1:4035 ELECTRIC RD STE A
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018
Practice Address - Country:US
Practice Address - Phone:540-772-8670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-30
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110006532363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant