Healthcare Provider Details

I. General information

NPI: 1912547597
Provider Name (Legal Business Name): DEREK RYAN ALLEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2020
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6644 E BAYWOOD AVE
MESA AZ
85206-1747
US

IV. Provider business mailing address

1101 N GILBERT RD APT 1111
GILBERT AZ
85234-8611
US

V. Phone/Fax

Practice location:
  • Phone: 480-321-2000
  • Fax:
Mailing address:
  • Phone: 480-294-9223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN174073
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: