Provider Demographics
NPI:1528671393
Name:MANNS, DERQUAN J
Entity type:Individual
Prefix:
First Name:DERQUAN
Middle Name:J
Last Name:MANNS
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:PO BOX 1825
Mailing Address - Street 2:
Mailing Address - City:OCEANA
Mailing Address - State:WV
Mailing Address - Zip Code:24870-1825
Mailing Address - Country:US
Mailing Address - Phone:304-918-4480
Mailing Address - Fax:
Practice Address - Street 1:54 72ND ST
Practice Address - Street 2:
Practice Address - City:KOPPERSTON
Practice Address - State:WV
Practice Address - Zip Code:24854
Practice Address - Country:US
Practice Address - Phone:304-918-4480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant