Provider Demographics
NPI:1487004636
Name:PORT, DEREK (ATC)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:
Last Name:PORT
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY DR
Mailing Address - Street 2:UPO #823
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-2190
Mailing Address - Country:US
Mailing Address - Phone:270-789-5544
Mailing Address - Fax:270-789-5199
Practice Address - Street 1:1 UNIVERSITY DR
Practice Address - Street 2:UPO #823
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-2190
Practice Address - Country:US
Practice Address - Phone:270-789-5544
Practice Address - Fax:270-789-5199
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT5122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer