Provider Demographics
NPI:1447782933
Name:DERR, NOLAN (MD)
Entity Type:Individual
Prefix:
First Name:NOLAN
Middle Name:
Last Name:DERR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-0189
Mailing Address - Country:US
Mailing Address - Phone:509-758-1450
Mailing Address - Fax:509-751-1504
Practice Address - Street 1:1119 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2836
Practice Address - Country:US
Practice Address - Phone:509-254-2722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-03
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1447782933207R00000X
OH1447782933207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine