Individual
DEREK MARC PROVENCHER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT, DPT
Contact information
Practice address
16037B TAMPA PALMS BLVD W, TAMPA, FL 33647-2001
(813) 542-8188
Mailing address
9309 PERSIMMON BROOK TRL APT 215, THONOTOSASSA, FL 33592-3963
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PTT40333
—
Other
Enumeration date
08/07/2023
Last updated
08/15/2023
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