Healthcare Provider Details

I. General information

NPI: 1841454956
Provider Name (Legal Business Name): DEREK LEONARD HINES CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 GAUSE BLVD SUITE 200
SLIDELL LA
70458-2007
US

IV. Provider business mailing address

PO BOX 3249
SLIDELL LA
70459-3249
US

V. Phone/Fax

Practice location:
  • Phone: 985-641-8008
  • Fax: 985-649-4063
Mailing address:
  • Phone: 985-641-8008
  • Fax: 985-649-4063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP05510
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: