Healthcare Provider Details

I. General information

NPI: 1689353930
Provider Name (Legal Business Name): KIRSTEN BAILEY DERICKS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIRSTEN BAILEY GAGEL PA-C

II. Dates (important events)

Enumeration Date: 07/13/2023
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3211 GRANT LINE RD STE 15
NEW ALBANY IN
47150-2175
US

IV. Provider business mailing address

3211 GRANT LINE RD STE 15
NEW ALBANY IN
47150-2175
US

V. Phone/Fax

Practice location:
  • Phone: 812-221-1186
  • Fax: 949-882-0452
Mailing address:
  • Phone: 812-221-1186
  • Fax: 949-882-0452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: