Provider Demographics
NPI:1578232310
Name:DANE, DEREK (PA-C)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:DANE
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 1:1426 COUNTY ROAD 436
Mailing Address - Street 2:
Mailing Address - City:DIME BOX
Mailing Address - State:TX
Mailing Address - Zip Code:77853-5248
Mailing Address - Country:US
Mailing Address - Phone:979-716-7915
Mailing Address - Fax:
Practice Address - Street 1:2700 E 29TH ST STE 260
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2587
Practice Address - Country:US
Practice Address - Phone:979-774-0012
Practice Address - Fax:979-774-4636
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA15097363A00000X
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1578232310Medicaid
TXQ00486203OtherRAILROAD MEDICARE