Provider Demographics
NPI:1952932642
Name:LAWHORN, DEREK ALLEN
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:ALLEN
Last Name:LAWHORN
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 1:1735 27TH ST STE B06
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2681
Mailing Address - Country:US
Mailing Address - Phone:740-356-7942
Mailing Address - Fax:740-356-7851
Practice Address - Street 1:835 W EMMITT AVE
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-1190
Practice Address - Country:US
Practice Address - Phone:740-947-7662
Practice Address - Fax:740-941-0099
Is Sole Proprietor?:No
Enumeration Date:2020-01-31
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.026256363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0393205Medicaid