Provider Demographics
NPI:1295218089
Name:DERKS, ANDREW JOHN ITUTUD (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:ANDREW JOHN
Middle Name:ITUTUD
Last Name:DERKS
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
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Mailing Address - Street 1:224-D CORNWALL STREET, NW, SUITE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:200 N GLEBE RD, 316,
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-3755
Practice Address - Country:US
Practice Address - Phone:703-729-3420
Practice Address - Fax:703-729-3422
Is Sole Proprietor?:No
Enumeration Date:2018-09-08
Last Update Date:2024-09-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0110009513363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30017944150001Medicaid
VA1295218089Medicaid