Healthcare Provider Details

I. General information

NPI: 1972390649
Provider Name (Legal Business Name): SHAWN DERBY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2025
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 26TH ST S
GREAT FALLS MT
59405-5161
US

IV. Provider business mailing address

PO BOX 6010
GREAT FALLS MT
59406-6010
US

V. Phone/Fax

Practice location:
  • Phone: 406-455-5200
  • Fax:
Mailing address:
  • Phone: 406-455-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNUR-APRN-LIC-266796
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN-69776
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: