Provider Demographics
NPI:1144810144
Name:WRIGHT, DERECK TA SHANTE (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:DERECK
Middle Name:TA SHANTE
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 AIR PARK AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75402-3000
Mailing Address - Country:US
Mailing Address - Phone:903-408-5834
Mailing Address - Fax:903-408-5693
Practice Address - Street 1:4215 JOE RAMSEY BLVD E
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-7852
Practice Address - Country:US
Practice Address - Phone:903-408-5834
Practice Address - Fax:903-408-5693
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1018209363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner