1144810144 NPI number — DERECK TA SHANTE WRIGHT AGACNP-BC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144810144 NPI number — DERECK TA SHANTE WRIGHT AGACNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WRIGHT
Provider First Name:
DERECK
Provider Middle Name:
TA SHANTE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AGACNP-BC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144810144
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 AIR PARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75402-3000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-408-5834
Provider Business Mailing Address Fax Number:
903-408-5693

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4215 JOE RAMSEY BLVD E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75401-7852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-408-5834
Provider Business Practice Location Address Fax Number:
903-408-5693
Provider Enumeration Date:
01/22/2021

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: 363L00000X , with the licence number:  1018209 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com