Provider Demographics
NPI:1669030540
Name:NYE, DERREK MATTHEW (PT)
Entity Type:Individual
Prefix:
First Name:DERREK
Middle Name:MATTHEW
Last Name:NYE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 LOWE RD UNIT 3109
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-8729
Mailing Address - Country:US
Mailing Address - Phone:620-655-5676
Mailing Address - Fax:
Practice Address - Street 1:460 S 14TH ST
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-3514
Practice Address - Country:US
Practice Address - Phone:972-723-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1318934225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist