Provider Demographics
NPI:1124825682
Name:SANDLES, DERRICK LASHAWN
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:LASHAWN
Last Name:SANDLES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9218 N 60TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223-1502
Mailing Address - Country:US
Mailing Address - Phone:262-349-6839
Mailing Address - Fax:
Practice Address - Street 1:9218 N 60TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-1502
Practice Address - Country:US
Practice Address - Phone:262-349-6839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver