Provider Demographics
NPI:1730726118
Name:CHRISTIANSEN, DEREK JAMES
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:JAMES
Last Name:CHRISTIANSEN
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 1:1604 LEGEND HILL LN
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-8088
Mailing Address - Country:US
Mailing Address - Phone:262-880-4664
Mailing Address - Fax:262-447-0850
Practice Address - Street 1:1604 LEGEND HILL LN
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53189-8088
Practice Address - Country:US
Practice Address - Phone:262-880-4664
Practice Address - Fax:262-447-0850
Is Sole Proprietor?:No
Enumeration Date:2019-12-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12576-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist