Provider Demographics
NPI:1215631742
Name:MILTON, DERRICK XABIEN
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:XABIEN
Last Name:MILTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2165 LARKSPUR LN
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-0600
Mailing Address - Country:US
Mailing Address - Phone:530-226-7419
Mailing Address - Fax:530-262-6849
Practice Address - Street 1:414 4TH ST STE D
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-4000
Practice Address - Country:US
Practice Address - Phone:530-406-7993
Practice Address - Fax:530-262-6849
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-28
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CA63188390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant