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General NPI Number Information
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NPI Number | 1053855296
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Entity Type | Individual
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Provider Name | DEREK MEDEIROS R.T, R.R.A, R.P.A
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Gender | Male
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Dates
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Enumeration Date | 12/07/2016
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Last Update Date | 12/07/2016
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Provider Practice Location Address
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Address Line | 6836 MORRISON BLVD STE 101
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City | CHARLOTTE
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State | NC
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Zip | 28211-2612
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Country | US
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Telephone | 704-817-0821
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Fax | 704-817-0835
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Provider Business Mailing Address
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Address Line | 6836 MORRISON BLVD SUITE 101
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City | CHARLOTTE
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State | NC
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Zip | 28211-2612
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Country | US
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Telephone | 704-817-0821
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Fax | 704-817-0835
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 243U00000X
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Taxonomy Name | Radiology Practitioner Assistant
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License Number | 15MA1496
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License Number State | MA
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