MEDICARE: J DEREK BREDERSON FNP

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	363LF0000X	Family Nurse Practitioner	336768	NY

General Provider Information

NPI Number	:	1790063162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	J DEREK BREDERSON FNP

Provider Business Mailing Address
First Line	:	14 MAIDEN LN
Second Line	:
City	:	PENN YAN
State	:	NY
Zip	:	14527-1208
Country	:	US
Telephone Number	:	315-531-9102
Fax Number	:	315-531-9103

Provider Business Practice Location Address
First Line	:	60 MAIN ST
Second Line	:
City	:	PORT BYRON
State	:	NY
Zip	:	13140-0359
Country	:	US
Telephone Number	:	315-776-9700
Fax Number	:	315-776-9701

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

Provider Enumeration Date	:	08/02/2011
Last Update Date	:	02/14/2014

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