Healthcare Provider Details

I. General information

NPI: 1205380763
Provider Name (Legal Business Name): DEREK GELVEN SRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2016
Last Update Date: 08/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 PARK FOREST DR STE 210
TRAVERSE CITY MI
49684-7306
US

IV. Provider business mailing address

3617 BLAIR VALLEY DR
TRAVERSE CITY MI
49685-7049
US

V. Phone/Fax

Practice location:
  • Phone: 231-392-8742
  • Fax: 231-935-0747
Mailing address:
  • Phone: 248-701-5575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704286642
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: