Provider Demographics
NPI:1467202432
Name:SMITH, DERRECK
Entity Type:Individual
Prefix:
First Name:DERRECK
Middle Name:
Last Name:SMITH
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 1:2317 3RD AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98121-1732
Mailing Address - Country:US
Mailing Address - Phone:206-602-7928
Mailing Address - Fax:
Practice Address - Street 1:1700 AIRPORT WAY S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98134-1618
Practice Address - Country:US
Practice Address - Phone:206-971-8830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician