Provider Demographics
NPI:1205238086
Name:URBAN, DEREK JOSEPH
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:JOSEPH
Last Name:URBAN
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 1:1531 ESPLANADE
Mailing Address - Street 2:BOX 72
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-3310
Mailing Address - Country:US
Mailing Address - Phone:530-332-4470
Mailing Address - Fax:530-893-6885
Practice Address - Street 1:1531 ESPLANADE
Practice Address - Street 2:BOX 72
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-3310
Practice Address - Country:US
Practice Address - Phone:530-332-4470
Practice Address - Fax:530-893-6885
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51961363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant