Provider Demographics
NPI:1346749074
Name:DER GHAZARIAN, JOHN (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DER GHAZARIAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 GUARDIAN CT
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-3017
Mailing Address - Country:US
Mailing Address - Phone:252-210-9015
Mailing Address - Fax:252-632-0242
Practice Address - Street 1:90 GUARDIAN CT
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-3017
Practice Address - Country:US
Practice Address - Phone:252-210-9015
Practice Address - Fax:252-632-0242
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2024-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12430363A00000X
390200000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program