Provider Demographics
NPI:1437552601
Name:THOMAS, DERRICK (PA-C)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:THOMAS
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 1:22 INDUSTRIAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15825-7228
Mailing Address - Country:US
Mailing Address - Phone:814-849-0990
Mailing Address - Fax:
Practice Address - Street 1:22 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:PA
Practice Address - Zip Code:15825-7228
Practice Address - Country:US
Practice Address - Phone:814-849-0990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-02
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057041363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical