Provider Demographics
NPI:1912591108
Name:RODRIGUEZ, DERRICK LEMUEL (NP-C)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:LEMUEL
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1915
Mailing Address - Country:US
Mailing Address - Phone:551-455-4453
Mailing Address - Fax:
Practice Address - Street 1:30 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1915
Practice Address - Country:US
Practice Address - Phone:551-455-4453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-27
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01121100363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner