Provider Demographics
NPI:1538686464
Name:DERR, JOSEPH (CPNP-AC)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:DERR
Suffix:
Gender:M
Credentials:CPNP-AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5419 LARKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-3635
Mailing Address - Country:US
Mailing Address - Phone:614-203-6987
Mailing Address - Fax:
Practice Address - Street 1:700 CHILDRENS DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2664
Practice Address - Country:US
Practice Address - Phone:614-722-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.021668363LA2100X, 363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0242136Medicaid