Provider Demographics
NPI:1568207298
Name:MARSHALL, DEREK JUSTIN
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:JUSTIN
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6939 OLD WAGON RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:WA
Mailing Address - Zip Code:98236-8735
Mailing Address - Country:US
Mailing Address - Phone:425-971-1262
Mailing Address - Fax:
Practice Address - Street 1:6939 OLD WAGON RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:WA
Practice Address - Zip Code:98236-8735
Practice Address - Country:US
Practice Address - Phone:425-971-1262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN61277081163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse