Healthcare Provider Details

I. General information

NPI: 1609646553
Provider Name (Legal Business Name): DEREK PAUL DEYOUNG RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 01/27/2024
Certification Date: 01/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 FOREST AVE
BUFFALO NY
14213-1207
US

IV. Provider business mailing address

14 SYLVAN PKWY
AKRON NY
14001-1514
US

V. Phone/Fax

Practice location:
  • Phone: 716-816-2444
  • Fax: 716-816-2161
Mailing address:
  • Phone: 716-812-5356
  • Fax: 716-816-2161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number635025
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: