Healthcare Provider Details

I. General information

NPI: 1639893621
Provider Name (Legal Business Name): DEREK WADE JOYNER CSFA, OA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5716 CLEVELAND ST
VIRGINIA BEACH VA
23462-1784
US

IV. Provider business mailing address

15765 BREEZY HILL LN
SMITHFIELD VA
23430-6681
US

V. Phone/Fax

Practice location:
  • Phone: 757-490-4802
  • Fax:
Mailing address:
  • Phone: 757-758-0904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number0136000028
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code246ZX2200X
TaxonomyOrthopedic Assistant
License Number1206
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: