Provider Demographics
NPI:1932664943
Name:AMAR, DERRICK SEBASTIAN
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:SEBASTIAN
Last Name:AMAR
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 1:38144 WILLOW LAKE EAST AVE
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-4176
Mailing Address - Country:US
Mailing Address - Phone:225-572-9271
Mailing Address - Fax:
Practice Address - Street 1:4021 WE HECK CT STE 2
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-0416
Practice Address - Country:US
Practice Address - Phone:225-302-5804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator