Brandt Derrickson, ATC

Primary specialty

Athletic TrainerTaxonomy code 2255A2300X

License

2016004534 Issued in MO

Practice address

1155 W Parkview St Ste 2D
Bolivar, MO 65613-7800

Phone

(417) 777-2663

Fax

(417) 326-2666

NPI assigned

Oct 18, 2016

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1476748800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1476748800000",
    "number": "1932650736",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1500 N OAKLAND AVE",
            "city": "BOLIVAR",
            "state": "MO",
            "postal_code": "656133011",
            "telephone_number": "417-326-6000",
            "fax_number": "417-328-6338"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1155 W PARKVIEW ST STE 2D",
            "city": "BOLIVAR",
            "state": "MO",
            "postal_code": "656137800",
            "telephone_number": "417-777-2663",
            "fax_number": "417-326-2666"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DERRICKSON",
        "first_name": "BRANDT",
        "name_prefix": "Mr.",
        "credential": "ATC",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2016-10-18",
        "last_updated": "2016-10-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2255A2300X",
            "taxonomy_group": "",
            "desc": "Specialist/Technologist, Athletic Trainer",
            "state": "MO",
            "license": "2016004534",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Athletic Trainer in Bolivar, MO
• Providers in Bolivar, MO by specialty
• Athletic Trainer in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 18, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.