MEDICARE: CAROL DERWACTER C.N.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	NP04044	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DENP03501	OTHER		MEDICARE PTAN
5	080146341	OTHER	OH	MEDICARE RAILROAD
6	CA1586	OTHER		GROUP MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	311413469060	OTHER	OH	CARESOURCE PIN

General Provider Information

NPI Number	:	1619953924
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROL DERWACTER C.N.P.

Provider Business Mailing Address
First Line	:	860 BETHESDA DR
Second Line	:
City	:	ZANESVILLE
State	:	OH
Zip	:	43701-1800
Country	:	US
Telephone Number	:	740-454-4651
Fax Number	:	740-454-4653

Provider Business Practice Location Address
First Line	:	2945 MAPLE AVE
Second Line	:
City	:	ZANESVILLE
State	:	OH
Zip	:	43701-1753
Country	:	US
Telephone Number	:	740-454-0196
Fax Number	:	740-454-7834

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2005
Last Update Date	:	08/19/2008

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Directions to “ CAROL DERWACTER C.N.P.” Practice Location

Language	Start Address	Practice Location

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