Healthcare Provider Details

I. General information

NPI: 1972677367
Provider Name (Legal Business Name): DERECK PETTIFORD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 SW 33RD RD
OCALA FL
34474-7458
US

IV. Provider business mailing address

8235 SW 72ND PL
GAINESVILLE FL
32608-8425
US

V. Phone/Fax

Practice location:
  • Phone: 352-873-9311
  • Fax:
Mailing address:
  • Phone: 352-380-2724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3280462
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: