Healthcare Provider Details

I. General information

NPI: 1588094882
Provider Name (Legal Business Name): DEREK JASON BROCK CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2013
Last Update Date: 07/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 E SIMPSON ST
ALLIANCE OH
44601-4219
US

IV. Provider business mailing address

PO BOX 932100
CLEVELAND OH
44193-0008
US

V. Phone/Fax

Practice location:
  • Phone: 330-823-3856
  • Fax: 330-829-6688
Mailing address:
  • Phone: 216-472-2730
  • Fax: 216-472-2740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA.15415-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: