Provider Demographics
NPI:1902850340
Name:COUPE, DERRICK (CRNA)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:COUPE
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 1:7912 E 31ST CT
Mailing Address - Street 2:STE 210
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-1315
Mailing Address - Country:US
Mailing Address - Phone:918-392-4477
Mailing Address - Fax:918-392-4465
Practice Address - Street 1:8801 S 101ST EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5716
Practice Address - Country:US
Practice Address - Phone:918-294-4915
Practice Address - Fax:918-294-4947
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0069640367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK900522349OtherMEDICARE GROUP PIN
OK200052000AMedicaid
OK24960510Medicare PIN