Provider Demographics
NPI:1669817920
Name:ROSA, DEREK CHRISTOPHER (MPT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:CHRISTOPHER
Last Name:ROSA
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 BENNETT RD
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-4507
Mailing Address - Country:US
Mailing Address - Phone:831-239-7144
Mailing Address - Fax:
Practice Address - Street 1:9565 SOQUEL DR
Practice Address - Street 2:SUITE 204
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-4152
Practice Address - Country:US
Practice Address - Phone:831-239-7144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-30
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA259522251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports