Healthcare Provider Details

I. General information

NPI: 1861723496
Provider Name (Legal Business Name): DEREK DEYOUNG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2010
Last Update Date: 06/07/2024
Certification Date: 06/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 EDWARDS MILL RD SUITE 200
RALEIGH NC
27612-5243
US

IV. Provider business mailing address

3001 EDWARDS MILL RD STE 200
RALEIGH NC
27612-5243
US

V. Phone/Fax

Practice location:
  • Phone: 919-781-5600
  • Fax: 919-782-6578
Mailing address:
  • Phone: 919-781-5600
  • Fax: 919-863-6821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-05275
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: