Provider Demographics
NPI:1962668657
Name:BOYD, DERRICK (PA)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:
Last Name:BOYD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:MR
Other - First Name:DERRICK
Other - Middle Name:
Other - Last Name:BOYD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:561 FAIRTHORNE AVE
Mailing Address - Street 2:FAIRMOUNT BEHAVIORAL HEALTH SYSTEM
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:267-582-3405
Practice Address - Street 1:561 FAIRTHORNE AVE.
Practice Address - Street 2:FAIRMOUNT BEHAVIORAL HEALTH SYSTEM
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128
Practice Address - Country:US
Practice Address - Phone:215-582-3405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-01
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003235L363AM0700X, 363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA394797P4RMedicare PIN