Healthcare Provider Details

I. General information

NPI: 1720497597
Provider Name (Legal Business Name): DERRICK EVAN PICKERING N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 03/03/2023
Certification Date: 03/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 S 1600 W STE 200
MAPLETON UT
84664-4349
US

IV. Provider business mailing address

724 S 1600 W STE 200
MAPLETON UT
84664-4349
US

V. Phone/Fax

Practice location:
  • Phone: 385-448-0055
  • Fax:
Mailing address:
  • Phone: 385-448-0055
  • Fax: 801-797-0281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7675886-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: