Provider Demographics
NPI:1457927295
Name:DIBBEN, DEREK (DNP, CRNA)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:DIBBEN
Suffix:
Gender:M
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 WESTOVER CT
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:MO
Mailing Address - Zip Code:64012-1844
Mailing Address - Country:US
Mailing Address - Phone:816-806-9287
Mailing Address - Fax:
Practice Address - Street 1:7301 N 16TH ST STE 102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-5266
Practice Address - Country:US
Practice Address - Phone:480-420-4027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ259670367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered