Provider Demographics
NPI:1659480630
Name:DERRICK, ELLEN LYMAN THOMASON (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:LYMAN THOMASON
Last Name:DERRICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:L
Other - Last Name:THOMASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6541 50TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115
Mailing Address - Country:US
Mailing Address - Phone:206-818-6905
Mailing Address - Fax:
Practice Address - Street 1:3216 NE 45TH PL STE 207
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-4028
Practice Address - Country:US
Practice Address - Phone:206-596-3976
Practice Address - Fax:206-486-9013
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000458732086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1659480630Medicaid
G8902722Medicare UPIN