Provider Demographics
NPI:1649803172
Name:DERRICK, RICHARD L (CRNA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:DERRICK
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 1:735 S PEACHTREE DR
Mailing Address - Street 2:
Mailing Address - City:TOQUERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84774-5079
Mailing Address - Country:US
Mailing Address - Phone:180-166-4234
Mailing Address - Fax:770-701-6675
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3175
Practice Address - Country:US
Practice Address - Phone:207-662-2526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9469329163W00000X
UT9639260-4406367500000X
VA0024179084367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse