Healthcare Provider Details

I. General information

NPI: 1215412309
Provider Name (Legal Business Name): KATHRYN JENNY DERRICK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2018
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

991 E DEL WEBB BLVD
SUN CITY CENTER FL
33573-6669
US

IV. Provider business mailing address

13020 N TELECOM PKWY
TEMPLE TERRACE FL
33637-0915
US

V. Phone/Fax

Practice location:
  • Phone: 813-978-9700
  • Fax:
Mailing address:
  • Phone: 813-978-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number9111539
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9111539
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: