Provider Demographics
NPI:1720355571
Name:DEROULAC, JOHN DARNELL (PTA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DARNELL
Last Name:DEROULAC
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:232 LINBERG AVENUE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501
Mailing Address - Country:US
Mailing Address - Phone:956-682-7774
Mailing Address - Fax:956-682-7780
Practice Address - Street 1:232 LINBERG AVENUE
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78501
Practice Address - Country:US
Practice Address - Phone:956-682-7774
Practice Address - Fax:956-682-7780
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2084458225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant