Provider Demographics
NPI:1295081826
Name:YOUNG, DEREK ALAN (PT)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:ALAN
Last Name:YOUNG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2431 S LOOP 289
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-1519
Mailing Address - Country:US
Mailing Address - Phone:806-771-7661
Mailing Address - Fax:806-687-0534
Practice Address - Street 1:6202 82ND ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-3691
Practice Address - Country:US
Practice Address - Phone:806-687-8008
Practice Address - Fax:806-687-8009
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1224400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX320496802Medicaid
TX320496801Medicaid
TX881T55OtherBCBS
TXP01166355OtherMEDICARE RAILROAD
TX267275YNCJMedicare PIN