Provider Demographics
NPI:1942845029
Name:POWELL, DERRICK LASHUN
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:LASHUN
Last Name:POWELL
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 1:920 SIERRA VISTA DR APT A5
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89169-9347
Mailing Address - Country:US
Mailing Address - Phone:702-810-1342
Mailing Address - Fax:
Practice Address - Street 1:2780 S JONES BLVD # 105B
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-5628
Practice Address - Country:US
Practice Address - Phone:702-333-1488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant