Provider Demographics
NPI:1386223394
Name:STIBBENS, DEREK (ACNPC-AG)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:STIBBENS
Suffix:
Gender:M
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 267
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:CO
Mailing Address - Zip Code:80816-0267
Mailing Address - Country:US
Mailing Address - Phone:720-490-8735
Mailing Address - Fax:
Practice Address - Street 1:2304 COUNTY ROAD 102
Practice Address - Street 2:
Practice Address - City:GUFFEY
Practice Address - State:CO
Practice Address - Zip Code:80820
Practice Address - Country:US
Practice Address - Phone:720-490-8735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0996374363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care