Provider Demographics
NPI:1609533819
Name:NGUYEN, DERRICK JOHN (PT, DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:JOHN
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19768 YORBA LINDA BLVD
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-2801
Mailing Address - Country:US
Mailing Address - Phone:714-693-0460
Mailing Address - Fax:
Practice Address - Street 1:19768 YORBA LINDA BLVD
Practice Address - Street 2:
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-2801
Practice Address - Country:US
Practice Address - Phone:714-693-0460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300935225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist