Provider Demographics
NPI:1821618471
Name:ABELL, DERRIK
Entity Type:Individual
Prefix:
First Name:DERRIK
Middle Name:
Last Name:ABELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-1697
Mailing Address - Country:US
Mailing Address - Phone:618-833-4471
Mailing Address - Fax:
Practice Address - Street 1:513 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-1697
Practice Address - Country:US
Practice Address - Phone:618-833-4471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-23
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2020-0089363A00000X
390200000X
IL085.007900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program