Provider Demographics
NPI:1912547597
Name:ALLEN, DEREK RYAN (CRNA)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:RYAN
Last Name:ALLEN
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 1:1101 N GILBERT RD APT 1111
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-8611
Mailing Address - Country:US
Mailing Address - Phone:480-294-9223
Mailing Address - Fax:
Practice Address - Street 1:6644 E BAYWOOD AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1747
Practice Address - Country:US
Practice Address - Phone:480-321-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN174073367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered