Provider Demographics
NPI:1629270624
Name:PAGE, DERICK (PTA)
Entity Type:Individual
Prefix:MR
First Name:DERICK
Middle Name:
Last Name:PAGE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8132 OLD TAVERN RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-6807
Mailing Address - Country:US
Mailing Address - Phone:540-793-2415
Mailing Address - Fax:
Practice Address - Street 1:1330 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4842
Practice Address - Country:US
Practice Address - Phone:307-778-8997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306001374225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant