Healthcare Provider Details

I. General information

NPI: 1013488246
Provider Name (Legal Business Name): MR. DEREK JOHN TATUM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 03/30/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11020 HULL STREET RD
MIDLOTHIAN VA
23112-3200
US

IV. Provider business mailing address

5000 COX RD
GLEN ALLEN VA
23060-9263
US

V. Phone/Fax

Practice location:
  • Phone: 804-744-6310
  • Fax:
Mailing address:
  • Phone: 804-968-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110006682
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: