Provider Demographics
NPI:1649161019
Name:WALKER, DERRICK WAYNE (PRSS)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:WAYNE
Last Name:WALKER
Suffix:
Gender:M
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 10TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-2322
Mailing Address - Country:US
Mailing Address - Phone:304-523-0293
Mailing Address - Fax:
Practice Address - Street 1:624 10TH ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-2322
Practice Address - Country:US
Practice Address - Phone:304-523-0293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-14
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25-986SUD175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist