Basic Information
| Provider Information | |||||||||
| NPI: | 1215307145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCOY | ||||||||
| FirstName: | DERRON | ||||||||
| MiddleName: | LAMARR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9040 REID STREET, ATTN: MCHJ-CLQ-C | ||||||||
| Address2: | MADIGAN ARMY MEDICAL CENTER | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984311000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539681110 | ||||||||
| FaxNumber: | 8778741031 | ||||||||
| Practice Location | |||||||||
| Address1: | 9040 REID STREET, ATTN: MCHJ-CLQ-C | ||||||||
| Address2: | MADIGAN ARMY MEDICAL CENTER | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984311000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539681110 | ||||||||
| FaxNumber: | 8778741031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2015 | ||||||||
| LastUpdateDate: | 10/05/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146L00000X | 1769819 | Y | Emergency Medical Service Providers | Emergency Medical Technician, Paramedic |
No ID Information.