Provider Demographics
NPI:1023789005
Name:HASS, DERICK MITCHELL
Entity type:Individual
Prefix:
First Name:DERICK
Middle Name:MITCHELL
Last Name:HASS
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 1:3750 E COUNTRY FIELD CIR STE A
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6659
Mailing Address - Country:US
Mailing Address - Phone:907-376-7334
Mailing Address - Fax:
Practice Address - Street 1:3750 E COUNTRY FIELD CIR STE A
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6659
Practice Address - Country:US
Practice Address - Phone:907-376-7334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist