Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | 7288 | AZ |
NPI | 1053677625 |
---|---|
Provider Name | Dr. Lindsay Marie Derus |
First Address | Goodyear, AZ 85395-2629 |
Second Address | Goodyear, AZ 85395-2629 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/04/2012 |
Last Update Date | 08/05/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
139001 | (05) | OH |