Basic Information
| Provider Information | |||||||||
| NPI: | 1750435251 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERIUGIN | ||||||||
| FirstName: | TATIANA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 16TH AVE E | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981125226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063263000 | ||||||||
| FaxNumber: | 2063262785 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 16TH AVE E | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063263000 | ||||||||
| FaxNumber: | 2063262785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD00040879 | WA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 8344376 | 05 | WA | MEDICAID | 244386 | 01 | WA | L&I | OTHER |