Provider Demographics
NPI:1932719135
Name:NGORAN, DERICK YENSILA
Entity Type:Individual
Prefix:
First Name:DERICK
Middle Name:YENSILA
Last Name:NGORAN
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 1:620 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804-2771
Mailing Address - Country:US
Mailing Address - Phone:812-231-8323
Mailing Address - Fax:812-231-8400
Practice Address - Street 1:75 FENWOOD RD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6103
Practice Address - Country:US
Practice Address - Phone:617-626-9654
Practice Address - Fax:617-626-9531
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71010501A363LP0808X
NDR43593363LP0808X
MARN2365217363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health