Provider Demographics
NPI:1548284433
Name:DELOACH, DERRELL D (FNP-C)
Entity type:Individual
Prefix:
First Name:DERRELL
Middle Name:D
Last Name:DELOACH
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 S GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-1979
Mailing Address - Country:US
Mailing Address - Phone:806-350-3000
Mailing Address - Fax:806-467-9799
Practice Address - Street 1:2701 S GEORGIA ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-1979
Practice Address - Country:US
Practice Address - Phone:806-350-3000
Practice Address - Fax:806-350-3337
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX604578363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145651901Medicaid
TX1186100001OtherPALMETTO DMERC
TX604578OtherWORKER'S COMPENSATION
TXP00166964OtherRAILRAOD MEDICARE
TX1186100001OtherPALMETTO DMERC
TXP00166964OtherRAILRAOD MEDICARE