Provider Demographics
NPI:1578143822
Name:STRYDOM, DERRAN
Entity Type:Individual
Prefix:
First Name:DERRAN
Middle Name:
Last Name:STRYDOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12004 THORNBROOKE CT
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:VA
Mailing Address - Zip Code:20136-2423
Mailing Address - Country:US
Mailing Address - Phone:571-235-1982
Mailing Address - Fax:
Practice Address - Street 1:12004 THORNBROOKE CT
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:VA
Practice Address - Zip Code:20136-2423
Practice Address - Country:US
Practice Address - Phone:571-235-1982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer