Provider Demographics
NPI:1235289539
Name:DESHOTEL, DEREK J (CRNA)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:J
Last Name:DESHOTEL
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 1:211 4TH ST
Mailing Address - Street 2:BOX 30135
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-8421
Mailing Address - Country:US
Mailing Address - Phone:318-448-8440
Mailing Address - Fax:318-473-4340
Practice Address - Street 1:211 4TH ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-8421
Practice Address - Country:US
Practice Address - Phone:318-473-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA070004367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1674931Medicaid
LA5T907Medicare PIN