Provider Demographics
NPI:1316620800
Name:VANOUS, DEREK EDWARD (DPT)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:EDWARD
Last Name:VANOUS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18410 MCCLELLAN CIR
Mailing Address - Street 2:
Mailing Address - City:EAST GARRISON
Mailing Address - State:CA
Mailing Address - Zip Code:93933-4967
Mailing Address - Country:US
Mailing Address - Phone:785-955-0496
Mailing Address - Fax:
Practice Address - Street 1:2724 SOQUEL AVE STE B
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-1434
Practice Address - Country:US
Practice Address - Phone:831-475-2565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304588225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist