Provider Demographics
NPI:1023701349
Name:TINNEY, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:TINNEY
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 1:7510 DEER BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-3120
Mailing Address - Country:US
Mailing Address - Phone:304-872-9531
Mailing Address - Fax:
Practice Address - Street 1:901 BROAD ST STE 101
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1748
Practice Address - Country:US
Practice Address - Phone:304-872-9531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant