Provider Demographics
NPI:1790326478
Name:ANTES, DERRICK RYAN (DPT)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:RYAN
Last Name:ANTES
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7195 ADVANCED WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-3691
Mailing Address - Country:US
Mailing Address - Phone:702-740-5327
Mailing Address - Fax:702-740-5328
Practice Address - Street 1:7189 ADVANCED WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-3691
Practice Address - Country:US
Practice Address - Phone:702-777-7050
Practice Address - Fax:702-777-7051
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4085225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV250005707Medicaid