Healthcare Provider Details

I. General information

NPI: 1902314123
Provider Name (Legal Business Name): DEREK CHRISTIAN MAY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 12/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 82ND PKWY
MYRTLE BEACH SC
29572-4607
US

IV. Provider business mailing address

242 E PITT ST
BEDFORD PA
15522-1321
US

V. Phone/Fax

Practice location:
  • Phone: 843-692-1062
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number21554
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: