Basic Information
Provider Information | |||||||||
NPI: | 1114283124 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EWELL | ||||||||
FirstName: | DEREK | ||||||||
MiddleName: | ALLEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2710 HARNEY ST | ||||||||
Address2: | STE 100 | ||||||||
City: | LARAMIE | ||||||||
State: | WY | ||||||||
PostalCode: | 820720001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8063545417 | ||||||||
FaxNumber: | 8063513787 | ||||||||
Practice Location | |||||||||
Address1: | 1400 S COULTER ST | ||||||||
Address2: | TTUHSC | ||||||||
City: | AMARILLO | ||||||||
State: | TX | ||||||||
PostalCode: | 791061786 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8063545417 | ||||||||
FaxNumber: | 8063513787 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/03/2012 | ||||||||
LastUpdateDate: | 06/16/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207V00000X | 10577A | WY | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
No ID Information.