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General NPI Number Information
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NPI Number | 1598487035
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Entity Type | Individual
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Provider Name | DERRICK NICHOLAS DAMASO
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Gender | Male
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Dates
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Enumeration Date | 09/12/2022
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Last Update Date | 01/24/2023
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Provider Practice Location Address
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Address Line | 6136 LAKE MURRAY BLVD
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City | LA MESA
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State | CA
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Zip | 91942-2502
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Country | US
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Telephone | 877-693-6266
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Fax |
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Provider Business Mailing Address
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Address Line | 27741 GLACIER PL
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City | CASTAIC
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State | CA
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Zip | 91384-3729
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Country | US
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Telephone | 661-857-4918
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA62170
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License Number State | CA
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