Basic Information
| Provider Information | |||||||||
| NPI: | 1700166188 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DARNELL | ||||||||
| FirstName: | DEREK | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 603 CAMPUS DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ABINGDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242109700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2767398010 | ||||||||
| FaxNumber: | 2766281410 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 W STONE DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376606027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243701 | ||||||||
| FaxNumber: | 4232243709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2011 | ||||||||
| LastUpdateDate: | 06/05/2018 | ||||||||
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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 | 363A00000X | 1995 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0110003604 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P01048892 | 01 | VA | RR MEDICARE | OTHER | 1526508 | 05 | TN | MEDICAID | 1700166188 | 05 | VA | MEDICAID |