Provider Demographics
NPI:1023109030
Name:DERRY, SUSAN A (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:DERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5007
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98509-5007
Mailing Address - Country:US
Mailing Address - Phone:360-918-0119
Mailing Address - Fax:
Practice Address - Street 1:413 LILLY RD NE
Practice Address - Street 2:MSDDH09
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5133
Practice Address - Country:US
Practice Address - Phone:360-918-0119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8161176207P00000X
WAMD60547005207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDP62190Medicare UPIN