Provider Demographics
NPI:1538416367
Name:WEST, DEREK THOMAS (ATC)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:THOMAS
Last Name:WEST
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 RIO GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-7277
Mailing Address - Country:US
Mailing Address - Phone:605-730-2417
Mailing Address - Fax:
Practice Address - Street 1:2820 HPER CENTER
Practice Address - Street 2:SOUTH DAKOTA STATE UNIVERSITY
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57007-1497
Practice Address - Country:US
Practice Address - Phone:605-688-4003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD03762255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer