Healthcare Provider Details

I. General information

NPI: 1417324930
Provider Name (Legal Business Name): DEREK DONOVAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2015
Last Update Date: 04/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 WILLIAM F PALMER RD
MOODUS CT
06469-1132
US

IV. Provider business mailing address

28 CRESCENT ST
MIDDLETOWN CT
06457-3654
US

V. Phone/Fax

Practice location:
  • Phone: 860-873-1414
  • Fax: 860-358-8659
Mailing address:
  • Phone: 860-358-4820
  • Fax: 860-358-8661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-05911
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003652
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: