Provider Demographics
NPI:1801976352
Name:DERDERIAN, SHERYL (NP)
Entity type:Individual
Prefix:
First Name:SHERYL
Middle Name:
Last Name:DERDERIAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 CHESTNUT STREET
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199
Mailing Address - Country:US
Mailing Address - Phone:413-794-5700
Mailing Address - Fax:
Practice Address - Street 1:46 DAGGETT DRIVE
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089
Practice Address - Country:US
Practice Address - Phone:413-794-9110
Practice Address - Fax:413-794-9116
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA156396363LA2200X, 363LG0600X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA500025819OtherRAILROAD MEDICARE
MANP1137OtherCONNECTICARE
MA0344061Medicaid
MANP1137OtherBLUE CROSS
MANP1137OtherBLUE CROSS
MA0344061Medicaid