Provider Demographics
NPI:1811687429
Name:DERCO, DAVID (PTA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:DERCO
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 1:8100 HIGHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-1006
Mailing Address - Country:US
Mailing Address - Phone:952-831-7500
Mailing Address - Fax:
Practice Address - Street 1:8100 HIGHWOOD DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55438-1006
Practice Address - Country:US
Practice Address - Phone:952-831-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty