Provider Demographics
NPI:1780042630
Name:TAM, DERRICK (NP)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:
Last Name:TAM
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 1:9 COMSTOCK AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-1404
Mailing Address - Country:US
Mailing Address - Phone:347-466-3566
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST PH 5-505
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:347-466-3566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-07
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY705883163W00000X
NYF432636-01363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse