Basic Information
| Provider Information | |||||||||
| NPI: | 1912547597 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 N GILBERT RD APT 1111 | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852348611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802949223 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6644 E BAYWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852061747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803212000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2020 | ||||||||
| LastUpdateDate: | 01/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN174073 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.