Derek Donovan, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

003652 Issued in CT

Practice address

27 William F Palmer Rd
Moodus, CT 06469-1132

Phone

(860) 873-1414

Fax

(860) 358-8659

NPI assigned

Sep 1, 2015

Last updated

Apr 12, 2017By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1441065600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1491955200000",
    "number": "1417324930",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "28 CRESCENT ST",
            "city": "MIDDLETOWN",
            "state": "CT",
            "postal_code": "064573654",
            "telephone_number": "860-358-4820",
            "fax_number": "860-358-8661"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "27 WILLIAM F PALMER RD",
            "city": "MOODUS",
            "state": "CT",
            "postal_code": "064691132",
            "telephone_number": "860-873-1414",
            "fax_number": "860-358-8659"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DONOVAN",
        "first_name": "DEREK",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2015-09-01",
        "last_updated": "2017-04-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NC",
            "license": "0010-05911",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "CT",
            "license": "003652",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Physician Assistant in Moodus, CT
• Providers in Moodus, CT by specialty
• Physician Assistant in Connecticut

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 12, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.