Healthcare Provider Details

I. General information

NPI: 1871307041
Provider Name (Legal Business Name): DERICK NOWACKI CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2025
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 BRADDOCK AVE
BRADDOCK PA
15104-1856
US

IV. Provider business mailing address

3934 FOSTER ST APT B328
PITTSBURGH PA
15201-3271
US

V. Phone/Fax

Practice location:
  • Phone: 412-636-5050
  • Fax:
Mailing address:
  • Phone: 860-335-4560
  • Fax: 412-753-7627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberSP032116
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP032116
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberSP032116
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: