Provider Demographics
NPI:1457166589
Name:PULLEN, DERRICK JEFFREY JR
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:JEFFREY
Last Name:PULLEN
Suffix:JR
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 1:1944 ASPEN ST NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24017-7008
Mailing Address - Country:US
Mailing Address - Phone:540-314-2059
Mailing Address - Fax:
Practice Address - Street 1:1944 ASPEN ST NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017-7008
Practice Address - Country:US
Practice Address - Phone:540-314-2059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-07
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)