Provider Demographics
NPI:1033412440
Name:POULSON, DEREK S (CRNA)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:S
Last Name:POULSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57809 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46528-4402
Mailing Address - Country:US
Mailing Address - Phone:801-623-7813
Mailing Address - Fax:
Practice Address - Street 1:57809 HILLSIDE DR
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-4402
Practice Address - Country:US
Practice Address - Phone:801-623-7813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-08
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAA103025367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered