Provider Demographics
NPI:1144510538
Name:VARNEY, DEREK (PAC)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:VARNEY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3625
Mailing Address - Country:US
Mailing Address - Phone:570-621-5000
Mailing Address - Fax:570-621-5589
Practice Address - Street 1:735 NORMAN DR # DR3
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7559
Practice Address - Country:US
Practice Address - Phone:717-270-7908
Practice Address - Fax:717-272-1734
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA004216363A00000X
PAMA051903363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA051903OtherPA LICENSE NUMBER