Provider Demographics
NPI:1558349050
Name:DERECZYK, AMY (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:DERECZYK
Suffix:
Gender:F
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 1:4001 W MCNICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-3038
Mailing Address - Country:US
Mailing Address - Phone:313-993-1797
Mailing Address - Fax:313-993-1271
Practice Address - Street 1:4001 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-3038
Practice Address - Country:US
Practice Address - Phone:313-993-1797
Practice Address - Fax:313-993-1271
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003980363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
11712511OtherCAQH
MIP00043337Medicare ID - Type UnspecifiedRAILROAD
MIN86630007Medicare ID - Type UnspecifiedPEC OKW (PAS)