Provider Demographics
NPI:1205380763
Name:GELVEN, DEREK (SRNA)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:GELVEN
Suffix:
Gender:M
Credentials:SRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3617 BLAIR VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-7049
Mailing Address - Country:US
Mailing Address - Phone:248-701-5575
Mailing Address - Fax:
Practice Address - Street 1:4100 PARK FOREST DR STE 210
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7306
Practice Address - Country:US
Practice Address - Phone:231-392-8742
Practice Address - Fax:231-935-0747
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704286642367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered