Basic Information
| Provider Information | |||||||||
| NPI: | 1538686464 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERR | ||||||||
| FirstName: | JOSEPH | ||||||||
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| Credential: | CPNP-AC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5419 LARKWOOD RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432293635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142036987 | ||||||||
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| Practice Location | |||||||||
| Address1: | 700 CHILDRENS DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147222000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2017 | ||||||||
| LastUpdateDate: | 01/04/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | APRN.CNP.021668 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LP0222X | APRN.CNP.021668 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics, Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 0242136 | 05 | OH | MEDICAID |