Provider Demographics
NPI:1588094882
Name:BROCK, DEREK JASON (CNP)
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:JASON
Last Name:BROCK
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 932100
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0008
Mailing Address - Country:US
Mailing Address - Phone:216-472-2730
Mailing Address - Fax:216-472-2740
Practice Address - Street 1:149 E SIMPSON ST
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-4219
Practice Address - Country:US
Practice Address - Phone:330-823-3856
Practice Address - Fax:330-829-6688
Is Sole Proprietor?:No
Enumeration Date:2013-11-22
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.15415-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0095680Medicaid
OH0095680Medicaid