Provider Demographics
NPI:1104860956
Name:LAGEMANN, DEREK A (PT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:A
Last Name:LAGEMANN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 HINSON LOOP RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-3903
Mailing Address - Country:US
Mailing Address - Phone:501-301-4530
Mailing Address - Fax:501-251-1165
Practice Address - Street 1:1909 HINSON LOOP RD STE 100
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-3903
Practice Address - Country:US
Practice Address - Phone:501-301-4530
Practice Address - Fax:501-251-1165
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2616225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5X159OtherBLUE CROSS BLUE SHIELD
AR5X159C870Medicare PIN