Healthcare Provider Details

I. General information

NPI: 1023109030
Provider Name (Legal Business Name): SUSAN A DERRY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S MAIN ST
MOSCOW ID
83843-3046
US

IV. Provider business mailing address

4570 AVERY LN SE STE C203
LACEY WA
98503-5608
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-4511
  • Fax:
Mailing address:
  • Phone: 360-915-8586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number8161176
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD60547005
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: