Provider Demographics
NPI:1891540555
Name:STATEN, DERRICK K
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:K
Last Name:STATEN
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 1:518 MOUNT GERIZIM RD SE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-6410
Mailing Address - Country:US
Mailing Address - Phone:470-654-2331
Mailing Address - Fax:
Practice Address - Street 1:518 MOUNT GERIZIM RD SE
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-6410
Practice Address - Country:US
Practice Address - Phone:470-654-2331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA24064864343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)