Provider Demographics
NPI:1386480556
Name:DERR, ELIJAH
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
Last Name:DERR
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 1:727 PACKER ST
Mailing Address - Street 2:
Mailing Address - City:WEATHERLY
Mailing Address - State:PA
Mailing Address - Zip Code:18255-1612
Mailing Address - Country:US
Mailing Address - Phone:570-657-5566
Mailing Address - Fax:
Practice Address - Street 1:727 PACKER ST
Practice Address - Street 2:
Practice Address - City:WEATHERLY
Practice Address - State:PA
Practice Address - Zip Code:18255-1612
Practice Address - Country:US
Practice Address - Phone:570-657-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-06
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer