Individual
MR. DEREK RYAN ROBERTS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
300 TWINING ST, MAXWELL AFB, AL 36112-6027
(334) 953-3368
Mailing address
300 TWINING ST, MAXWELL AFB, AL 36112-6027
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
50.003912
OH
363A00000X
Physician Assistant
617
WV
363A00000X
Physician Assistant
Primary
PA9111316
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1772
WV PHYSICIAN ASSISTANT LICENSE
WV
01
—
50.003912
OHIO LICENSE
OH
01
—
AMD-666
HAWAII PHYSICIAN ASSISTANT LICENSE
HI
01
—
PA9111316
PHYSICIAN ASSISTANT
FL
Enumeration date
10/18/2013
Last updated
07/15/2024
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