Provider Demographics
NPI:1629830625
Name:OSOUP, DERRICK GLEN
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:GLEN
Last Name:OSOUP
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:PO BOX 433
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:AK
Mailing Address - Zip Code:99833-0433
Mailing Address - Country:US
Mailing Address - Phone:907-772-4963
Mailing Address - Fax:907-874-5190
Practice Address - Street 1:100 FRAM STREET
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:AK
Practice Address - Zip Code:99833
Practice Address - Country:US
Practice Address - Phone:907-772-4963
Practice Address - Fax:907-874-5190
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator