Provider Demographics
NPI:1780034959
Name:ALLEN, DERRYK (PA-C)
Entity Type:Individual
Prefix:
First Name:DERRYK
Middle Name:
Last Name:ALLEN
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 1:1100 S MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:UT
Mailing Address - Zip Code:84647-2222
Mailing Address - Country:US
Mailing Address - Phone:435-462-3471
Mailing Address - Fax:
Practice Address - Street 1:1100 S MEDICAL DR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:UT
Practice Address - Zip Code:84647-2222
Practice Address - Country:US
Practice Address - Phone:435-462-3471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5472057-1206363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical