Provider Demographics
NPI:1205296217
Name:MILLER, DERRICK JAMES (PTA)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:JAMES
Last Name:MILLER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-5239
Mailing Address - Country:US
Mailing Address - Phone:336-623-9712
Mailing Address - Fax:
Practice Address - Street 1:205 E KINGS HWY
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5239
Practice Address - Country:US
Practice Address - Phone:336-623-9712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5863225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant