Provider Demographics
NPI:1629674858
Name:WRIGHT, DEREK (PA)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 N FAIR OAKS AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-3618
Mailing Address - Country:US
Mailing Address - Phone:626-696-1400
Mailing Address - Fax:
Practice Address - Street 1:3434 MIDWAY DR STE 2001
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4924
Practice Address - Country:US
Practice Address - Phone:619-325-1161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-11
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59158363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty