Provider Demographics
NPI:1508462862
Name:QUAN, DEREK (NP-C)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:QUAN
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17855 DALLAS PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-6857
Mailing Address - Country:US
Mailing Address - Phone:346-376-1702
Mailing Address - Fax:224-532-2780
Practice Address - Street 1:3110 E GUASTI RD
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-1219
Practice Address - Country:US
Practice Address - Phone:858-592-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015979363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily