Provider Demographics
NPI:1619953924
Name:DERWACTER, CAROL (CNP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:DERWACTER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 BETHESDA DR
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-1800
Mailing Address - Country:US
Mailing Address - Phone:740-454-4651
Mailing Address - Fax:740-454-4653
Practice Address - Street 1:2945 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-1753
Practice Address - Country:US
Practice Address - Phone:740-454-0196
Practice Address - Fax:740-454-7834
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP04044363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DENP03501OtherMEDICARE PTAN
OH0989499OtherGROUP MEDICAID
OH2043354Medicaid
OH311413469060OtherCARESOURCE PIN
OH080146341OtherMEDICARE RAILROAD
CA1586OtherGROUP MEDICARE RAILROAD
9270903Medicare PIN
OH0989499OtherGROUP MEDICAID
DENP03501Medicare PIN