Provider Demographics
NPI:1992971600
Name:SNODGRASS, DEREK WADE (DC)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:WADE
Last Name:SNODGRASS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 JAMES SANDERS BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-8405
Mailing Address - Country:US
Mailing Address - Phone:270-554-5114
Mailing Address - Fax:270-554-5021
Practice Address - Street 1:2725 JAMES SANDERS BLVD
Practice Address - Street 2:STEW A
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-8405
Practice Address - Country:US
Practice Address - Phone:270-554-5114
Practice Address - Fax:270-554-5021
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5190111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0961012Medicare PIN