Basic Information
| Provider Information | |||||||||
| NPI: | 1164756664 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEST | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | ACNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1230 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477061230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124506815 | ||||||||
| FaxNumber: | 8128584586 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 MARY ST STE 230 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477101678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124649133 | ||||||||
| FaxNumber: | 8124640559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2009 | ||||||||
| LastUpdateDate: | 07/31/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 71003054 | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363L00000X | 71003054 | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 200975230 | 05 | IN | MEDICAID | 7100101320 | 05 | KY | MEDICAID | 000000637973 | 01 | IN | ANTHEM | OTHER |