Provider Demographics
NPI:1982970737
Name:WHITE, DERECK (LMP)
Entity type:Individual
Prefix:
First Name:DERECK
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 30TH ST SE
Mailing Address - Street 2:#25
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-8192
Mailing Address - Country:US
Mailing Address - Phone:206-909-2693
Mailing Address - Fax:
Practice Address - Street 1:1221 30TH ST SE
Practice Address - Street 2:#25
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-8192
Practice Address - Country:US
Practice Address - Phone:206-909-2693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60272581171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor