Provider Demographics
NPI:1528709912
Name:DERICK, MARCUS LINCOLN
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:LINCOLN
Last Name:DERICK
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 1:600 UNIVERSITY AVE
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709
Mailing Address - Country:US
Mailing Address - Phone:907-371-2240
Mailing Address - Fax:
Practice Address - Street 1:600 UNIVERSITY AVE
Practice Address - Street 2:SUITE 2B
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709
Practice Address - Country:US
Practice Address - Phone:907-371-2240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No172V00000XOther Service ProvidersCommunity Health Worker
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist