Provider Demographics
NPI:1720157720
Name:DERKACS, DEREK (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:
Last Name:DERKACS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E. IDAHO ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712
Mailing Address - Country:US
Mailing Address - Phone:208-381-2733
Mailing Address - Fax:208-381-2482
Practice Address - Street 1:100 E. IDAHO ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712
Practice Address - Country:US
Practice Address - Phone:208-381-2733
Practice Address - Fax:208-381-2482
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-740363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant