1912538562 NPI number — KATHLEEN SARAH DERR PA-C

Table of content: KATHLEEN SARAH DERR PA-C (NPI 1912538562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912538562 NPI number — KATHLEEN SARAH DERR PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DERR
Provider First Name:
KATHLEEN
Provider Middle Name:
SARAH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HITT
Provider Other First Name:
KATHLEEN
Provider Other Middle Name:
SARAH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1912538562
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3170 KETTERING BLVD BLDG B3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORAINE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45439-1924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-991-3188
Provider Business Mailing Address Fax Number:
937-223-9811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 E APPLE ST STE 5254
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45409-2939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-208-4200
Provider Business Practice Location Address Fax Number:
937-208-2678
Provider Enumeration Date:
02/03/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  50.006351RX , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)