Healthcare Provider Details

I. General information

NPI: 1043735509
Provider Name (Legal Business Name): DEREK L ROBERTS APRN-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2017
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 E 22ND ST N STE 1600-B
WICHITA KS
67226-2321
US

IV. Provider business mailing address

8100 E 22ND ST N STE 1600-B
WICHITA KS
67226-2321
US

V. Phone/Fax

Practice location:
  • Phone: 316-201-6424
  • Fax: 316-201-6428
Mailing address:
  • Phone: 316-201-6424
  • Fax: 316-201-6428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number53-77798-092
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: