Provider Demographics
NPI:1679535413
Name:DEREMER, KEVIN LEROY (ATC)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:LEROY
Last Name:DEREMER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13927 PINE ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-1152
Mailing Address - Country:US
Mailing Address - Phone:402-697-3892
Mailing Address - Fax:
Practice Address - Street 1:CREIGHTON UNIVERSITY DEPT. OF ATHLETICS
Practice Address - Street 2:2500 CALIFORNIA PLAZA
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68178-0001
Practice Address - Country:US
Practice Address - Phone:402-280-1793
Practice Address - Fax:402-280-3110
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer