Provider Demographics
NPI:1902496862
Name:DAVIS, DERRICK OLASHAJAUN
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:OLASHAJAUN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 KAREN AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89169-8701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1750 KAREN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-8701
Practice Address - Country:US
Practice Address - Phone:916-848-9358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-24
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide