Basic Information
| Provider Information | |||||||||
| NPI: | 1932859865 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKENNA | ||||||||
| FirstName: | DEREK | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33 LEWIS RD | ||||||||
| Address2: | 2ND FL | ||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077700025 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10-42 MITCHELL AVE | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139031617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077622990 | ||||||||
| FaxNumber: | 6077622639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2022 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 404367 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.