Provider Demographics
NPI:1093797961
Name:DERR, TINA FAITH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:FAITH
Last Name:DERR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 SOUTH THIRD STREET
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:WA
Mailing Address - Zip Code:99328
Mailing Address - Country:US
Mailing Address - Phone:509-382-2531
Mailing Address - Fax:509-382-9359
Practice Address - Street 1:1012 SOUTH THIRD STREET
Practice Address - Street 2:COLUMBIA FAMILY CLINIC
Practice Address - City:DAYTON
Practice Address - State:WA
Practice Address - Zip Code:99328
Practice Address - Country:US
Practice Address - Phone:509-382-3200
Practice Address - Fax:509-382-2748
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2004-0030363A00000X
WAPA60426271363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPA2004-0030OtherPA LICENSE
NM83320253Medicaid
NM83320253Medicaid
Q39107Medicare UPIN