Healthcare Provider Details

I. General information

NPI: 1477583649
Provider Name (Legal Business Name): DEREK G DENNIS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 01/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2537 W STATE ST
BOISE ID
83702-2200
US

IV. Provider business mailing address

2537 W STATE ST
BOISE ID
83702-2200
US

V. Phone/Fax

Practice location:
  • Phone: 208-336-0895
  • Fax: 208-338-1796
Mailing address:
  • Phone: 208-336-0895
  • Fax: 208-338-1796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA503
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: