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General NPI Number Information
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NPI Number | 1093797961
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Entity Type | Individual
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Provider Name | TINA FAITH DERR PA-C
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Gender | Female
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Dates
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Enumeration Date | 11/16/2005
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 1012 SOUTH THIRD STREET COLUMBIA FAMILY CLINIC
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City | DAYTON
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State | WA
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Zip | 99328
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Country | US
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Telephone | 509-382-3200
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Fax | 509-382-2748
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Provider Business Mailing Address
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Address Line | 1012 SOUTH THIRD STREET
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City | DAYTON
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State | WA
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Zip | 99328
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Country | US
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Telephone | 509-382-2531
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Fax | 509-382-9359
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA2004-0030
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA60426271
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License Number State | WA
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