Provider Demographics
NPI:1881136679
Name:ROSS, DEREK (ATC)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:ROSS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45511 TRAIL RUN TER
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-5233
Mailing Address - Country:US
Mailing Address - Phone:703-867-4335
Mailing Address - Fax:
Practice Address - Street 1:45511 TRAIL RUN TER
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-5233
Practice Address - Country:US
Practice Address - Phone:703-867-4335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260000632255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer