Active NPI
Derek Ryan Roberts, PA-C
- Physician Assistant
- Maxwell Afb, AL
National Provider Identifier
1821426362
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- PA9111316
- Practice address
- 300 Twining St
Maxwell Afb, AL 36112-6027 - Phone
- (334) 953-3368
- NPI assigned
- Oct 18, 2013
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 3
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | PA9111316 | FL | Primary |
| Physician Assistant | 363A00000X | 617 | WV | |
| Physician Assistant | 363A00000X | 50.003912 | OH |
Addresses
Primary practice location
300 Twining St
Maxwell Afb, AL 36112-6027
Mailing address
300 Twining St
Maxwell Afb, AL 36112-6027
Other identifiers 4
| Identifier | Type | State | Issuer |
|---|---|---|---|
| AMD-666 | Other | HI | HAWAII PHYSICIAN ASSISTANT LICENSE |
| 1772 | Other | WV | WV PHYSICIAN ASSISTANT LICENSE |
| 50.003912 | Other | OH | OHIO LICENSE |
| PA9111316 | Other | FL | PHYSICIAN ASSISTANT |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 617 | WV | MD | Professional Counselor |
| PA9111316 | FL | MD | Physician Assistant |
| 50.003912 | OH | MD | Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1382054400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1721001600000",
"number": "1821426362",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "300 TWINING ST",
"city": "MAXWELL AFB",
"state": "AL",
"postal_code": "361126027"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "300 TWINING ST",
"city": "MAXWELL AFB",
"state": "AL",
"postal_code": "361126027",
"telephone_number": "334-953-3368"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ROBERTS",
"first_name": "DEREK",
"middle_name": "RYAN",
"name_prefix": "Mr.",
"credential": "PA-C",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2013-10-18",
"last_updated": "2024-07-15",
"certification_date": "2024-07-15",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "FL",
"license": "PA9111316",
"primary": true
},
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "WV",
"license": "617",
"primary": false
},
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "OH",
"license": "50.003912",
"primary": false
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "HAWAII PHYSICIAN ASSISTANT LICENSE",
"identifier": "AMD-666",
"state": "HI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "WV PHYSICIAN ASSISTANT LICENSE",
"identifier": "1772",
"state": "WV"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "OHIO LICENSE",
"identifier": "50.003912",
"state": "OH"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PHYSICIAN ASSISTANT",
"identifier": "PA9111316",
"state": "FL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Maxwell Afb, AL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 15, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.