Healthcare Provider Details

I. General information

NPI: 1982835724
Provider Name (Legal Business Name): DERRAL PROWANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2009
Last Update Date: 07/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121ST CSH UNIT 15244 BOX 805
APO AP
96205-5244
US

IV. Provider business mailing address

121ST CSH UNIT 15244 BOX 805
APO AP
96205-5244
US

V. Phone/Fax

Practice location:
  • Phone: 315-737-5430
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN128584
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: