Provider Demographics
NPI:1972390649
Name:DERBY, SHAWN
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:DERBY
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:PO BOX 6010
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59406-6010
Mailing Address - Country:US
Mailing Address - Phone:406-455-5000
Mailing Address - Fax:
Practice Address - Street 1:1101 26TH ST S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5161
Practice Address - Country:US
Practice Address - Phone:406-455-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-24
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN-69776163W00000X
MTNUR-APRN-LIC-266796363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse