Provider Demographics
NPI:1043051402
Name:NEILL, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:NEILL
Suffix:
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 1:8120 RUSE SPRINGS LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76131-5443
Mailing Address - Country:US
Mailing Address - Phone:817-907-7466
Mailing Address - Fax:
Practice Address - Street 1:4545 HERITAGE TRACE PKWY STE 1500
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-8938
Practice Address - Country:US
Practice Address - Phone:682-593-1231
Practice Address - Fax:346-202-0113
Is Sole Proprietor?:No
Enumeration Date:2024-06-01
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1164919363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily