Healthcare Provider Details

I. General information

NPI: 1255093647
Provider Name (Legal Business Name): DEREK BURYL HEMERICK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2021
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050A 2ND ST NE
KIRTLAND AFB NM
87108
US

IV. Provider business mailing address

2050A 2ND ST SE
KIRTLAND NM
87108
US

V. Phone/Fax

Practice location:
  • Phone: 505-843-3200
  • Fax:
Mailing address:
  • Phone: 505-846-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: