Provider Demographics
NPI:1750574729
Name:MONSON, DERRICK BLANE (PTA)
Entity type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:BLANE
Last Name:MONSON
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 1:508 SOUTH 9TH STREET
Mailing Address - Street 2:APT. # 13
Mailing Address - City:LAMAR
Mailing Address - State:CO
Mailing Address - Zip Code:81052-3239
Mailing Address - Country:US
Mailing Address - Phone:719-342-0195
Mailing Address - Fax:
Practice Address - Street 1:508 SOUTH 9TH STREET
Practice Address - Street 2:APT. # 13
Practice Address - City:LAMAR
Practice Address - State:CO
Practice Address - Zip Code:81052-3239
Practice Address - Country:US
Practice Address - Phone:719-342-0195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility