Provider Demographics
NPI:1790428894
Name:CARPENTER, DERRICK WILLIAM (PA-C)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:WILLIAM
Last Name:CARPENTER
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 1:64 LAVALE CT
Mailing Address - Street 2:
Mailing Address - City:LAVALE
Mailing Address - State:MD
Mailing Address - Zip Code:21502-7421
Mailing Address - Country:US
Mailing Address - Phone:301-697-6762
Mailing Address - Fax:
Practice Address - Street 1:12414 NAVES CROSSROAD NE
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502
Practice Address - Country:US
Practice Address - Phone:240-808-8482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0008960363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant