Provider Demographics
NPI:1124196340
Name:NORTHRUP, DERRICK (PT)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:NORTHRUP
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 1:605 TAYLOR LN
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-5169
Mailing Address - Country:US
Mailing Address - Phone:208-221-6952
Mailing Address - Fax:844-946-0909
Practice Address - Street 1:605 TAYLOR LN
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-5169
Practice Address - Country:US
Practice Address - Phone:208-221-6952
Practice Address - Fax:844-946-0909
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1280225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805245100Medicaid
IDT6939OtherBLUE CROSS OF IDAHO