Provider Demographics
NPI:1992208920
Name:HEAGGANS, DERRICK ANTHONY
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:ANTHONY
Last Name:HEAGGANS
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 1:1518 OAKCASK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-6031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7330 SAN PEDRO AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-6235
Practice Address - Country:US
Practice Address - Phone:210-857-3579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX203741164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse