Deitrick, Glen

Deitrick, Glen is an sole proprietor health care provider with primary practice located at 15190 Community Rd Suite 230A, Gulfport MS 39503-3485. He recently has only one registered license in Physician Assistants & Advanced Practice Nursing Providers / Nurse Anesthetist, Certified Registered, which is considered as his primary health care specialty. Deitrick, Glen can be contacted via phone (228) 831-0204.

Contact Information

Primary practice address
15190 Community Rd Suite 230A Gulfport MS 39503-3485
Phone: (228) 831-0204
Fax: (228) 831-1868
Website:
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Health care specialties

SpecialtyCodeLicense #State
Physician Assistants & Advanced Practice Nursing Providers / Nurse Anesthetist, Certified Registered 367500000X R128610 Mississippi

Profile Details

NPI number 1033214564
LBN Legal business name Deitrick, Glen
Credentials Certified Registered Nurse Anesthetist (CRNA)
Entity Individual
Sole proprietor 1 Yes
Enumeration date Sep 13th, 2006
Last updated Jul 8th, 2007 - about 17 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1033214564 NPPES
Mississippi MEDICAID 00111157

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