Healthcare Provider Details

I. General information

NPI: 1598487035
Provider Name (Legal Business Name): DERRICK NICHOLAS DAMASO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6136 LAKE MURRAY BLVD
LA MESA CA
91942-2502
US

IV. Provider business mailing address

27741 GLACIER PL
CASTAIC CA
91384-3729
US

V. Phone/Fax

Practice location:
  • Phone: 877-693-6266
  • Fax:
Mailing address:
  • Phone: 661-857-4918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA62170
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: