Provider Demographics
NPI:1669130969
Name:CHAN, DERRICK (PT, DPT)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 GREEN MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:PA
Mailing Address - Zip Code:15666-9058
Mailing Address - Country:US
Mailing Address - Phone:281-723-0537
Mailing Address - Fax:
Practice Address - Street 1:100 EXCELA HEALTH DR # 101
Practice Address - Street 2:
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650-9001
Practice Address - Country:US
Practice Address - Phone:724-537-1266
Practice Address - Fax:724-537-6889
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT029339261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy