MEDICARE: ELLEN LYMAN THOMASON DERRICK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0129X	Vascular Surgery Physician	MD00045873	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659480630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN LYMAN THOMASON DERRICK MD

Provider Business Mailing Address
First Line	:	6541 50TH AVE NE
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98115
Country	:	US
Telephone Number	:	206-818-6905
Fax Number	:

Provider Business Practice Location Address
First Line	:	3216 NE 45TH PL STE 207
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98105-4028
Country	:	US
Telephone Number	:	206-596-3976
Fax Number	:	206-486-9013

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/21/2022

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