Healthcare Provider Details

I. General information

NPI: 1881136679
Provider Name (Legal Business Name): DEREK ROSS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45511 TRAIL RUN TER
STERLING VA
20164-5233
US

IV. Provider business mailing address

45511 TRAIL RUN TER
STERLING VA
20164-5233
US

V. Phone/Fax

Practice location:
  • Phone: 703-867-4335
  • Fax:
Mailing address:
  • Phone: 703-867-4335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126000063
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: