Healthcare Provider Details

I. General information

NPI: 1487299400
Provider Name (Legal Business Name): DERRICK LEE BARR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2019
Last Update Date: 08/16/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 S POLLARD ST
VINTON VA
24179-2502
US

IV. Provider business mailing address

415 S POLLARD ST
VINTON VA
24179-2502
US

V. Phone/Fax

Practice location:
  • Phone: 540-983-6700
  • Fax:
Mailing address:
  • Phone: 540-983-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110007000
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110007000
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: