Basic Information
| Provider Information | |||||||||
| NPI: | 1629680889 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUBAKER | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | GLENN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 539 W WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176033337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175755087 | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 N DUKE ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176022250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175444995 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2020 | ||||||||
| LastUpdateDate: | 08/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP022377 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.