Healthcare Provider Details

I. General information

NPI: 1124715149
Provider Name (Legal Business Name): DERIK TYLER GOTAY DNAP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 E ROOSEVELT ST
PHOENIX AZ
85008-4973
US

IV. Provider business mailing address

2929 E THOMAS RD
PHOENIX AZ
85016-8034
US

V. Phone/Fax

Practice location:
  • Phone: 602-344-5039
  • Fax:
Mailing address:
  • Phone: 602-470-5000
  • Fax: 602-470-5064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11026133
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD185139
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11026133
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number317291
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: