Healthcare Provider Details

I. General information

NPI: 1275626095
Provider Name (Legal Business Name): PHILLIP T DETURK NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 SAGAMORE PKWY WEST
WEST LAFAYETTE IN
47906
US

IV. Provider business mailing address

124 SAGAMORE PKWY WEST
WEST LAFAYETTE IN
47906
US

V. Phone/Fax

Practice location:
  • Phone: 765-463-6722
  • Fax: 765-463-0905
Mailing address:
  • Phone: 765-463-6722
  • Fax: 765-463-0905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71002161A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: