Provider Demographics
NPI:1194309989
Name:DERRA, IDRISSA
Entity type:Individual
Prefix:
First Name:IDRISSA
Middle Name:
Last Name:DERRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3906 TURNBRIDGE CT UNIT 311
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-3093
Mailing Address - Country:US
Mailing Address - Phone:216-801-5639
Mailing Address - Fax:
Practice Address - Street 1:3906 TURNBRIDGE CT UNIT 311
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-3093
Practice Address - Country:US
Practice Address - Phone:216-801-5639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-08
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor