Healthcare Provider Details

I. General information

NPI: 1063272334
Provider Name (Legal Business Name): DEREK B EASON AGNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2024
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1492 S MILL AVE STE 212
TEMPE AZ
85281-5664
US

IV. Provider business mailing address

1675 E MORTEN AVE UNIT 1120
PHOENIX AZ
85020-4639
US

V. Phone/Fax

Practice location:
  • Phone: 480-410-4128
  • Fax: 480-410-4130
Mailing address:
  • Phone: 801-694-5382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number305255
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: