Provider Demographics
NPI:1730133026
Name:DERKSEN, THOMAS V (NP)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:V
Last Name:DERKSEN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6550 FANNIN ST
Mailing Address - Street 2:SM1001
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2717
Mailing Address - Country:US
Mailing Address - Phone:713-441-0005
Mailing Address - Fax:713-790-6617
Practice Address - Street 1:6550 FANNIN ST
Practice Address - Street 2:SM1001
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2717
Practice Address - Country:US
Practice Address - Phone:713-441-0005
Practice Address - Fax:713-790-6617
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX731442363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1730133026OtherBLUE CROSS BLUE SHIELD
WI43983800Medicaid
009000261ROtherHUMANA
TX214435401Medicaid
WI43983800Medicaid
TX1730133026OtherBLUE CROSS BLUE SHIELD
P77663Medicare UPIN