Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 55049 | MN |
NPI | 1063402402 |
---|---|
Provider Name | Mr. Jeffrey James Derr |
First Address | St Cloud, MN 56303-5000 |
Second Address | St Cloud, MN 56303-5000 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/10/2005 |
Last Update Date | 04/01/2018 |