Basic Information
Provider Information | |||||||||
NPI: | 1619953924 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DERWACTER | ||||||||
FirstName: | CAROL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | C.N.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 860 BETHESDA DR | ||||||||
Address2: |   | ||||||||
City: | ZANESVILLE | ||||||||
State: | OH | ||||||||
PostalCode: | 437011800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7404544651 | ||||||||
FaxNumber: | 7404544653 | ||||||||
Practice Location | |||||||||
Address1: | 2945 MAPLE AVE | ||||||||
Address2: |   | ||||||||
City: | ZANESVILLE | ||||||||
State: | OH | ||||||||
PostalCode: | 437011753 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7404540196 | ||||||||
FaxNumber: | 7404547834 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/19/2005 | ||||||||
LastUpdateDate: | 08/19/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | NP04044 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
ID | Type | State | Issuer | Description | DENP03501 | 01 |   | MEDICARE PTAN | OTHER | 0989499 | 01 | OH | GROUP MEDICAID | OTHER | 2043354 | 05 | OH |   | MEDICAID | 311413469060 | 01 | OH | CARESOURCE PIN | OTHER | 080146341 | 01 | OH | MEDICARE RAILROAD | OTHER | CA1586 | 01 |   | GROUP MEDICARE RAILROAD | OTHER |