Basic Information
| Provider Information | |||||||||
| NPI: | 1841454956 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HINES | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | LEONARD | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3249 | ||||||||
| Address2: | |||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704593249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856418008 | ||||||||
| FaxNumber: | 9856494063 | ||||||||
| Practice Location | |||||||||
| Address1: | 636 GAUSE BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704582007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856418008 | ||||||||
| FaxNumber: | 9856494063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2008 | ||||||||
| LastUpdateDate: | 07/17/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | AP05510 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.