Basic Information
| Provider Information | |||||||||
| NPI: | 1235625377 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIXON | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | KENNETH | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1110 SHAWNEE RD | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458053529 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 16259 SYLVESTER RD SW | ||||||||
| Address2: | |||||||||
| City: | BURIEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981663049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062425186 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2018 | ||||||||
| LastUpdateDate: | 12/04/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.