Provider Demographics
NPI:1538413349
Name:PETERSON, DERRICK SCHUYLER
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:SCHUYLER
Last Name:PETERSON
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 518
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95741-0518
Mailing Address - Country:US
Mailing Address - Phone:916-402-2731
Mailing Address - Fax:
Practice Address - Street 1:3400 BRADSHAW RD
Practice Address - Street 2:SUITE A-5
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95827-2614
Practice Address - Country:US
Practice Address - Phone:916-415-8648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-31
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)