Provider Demographics
NPI:1063272334
Name:EASON, DEREK B (AGNP-C)
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:B
Last Name:EASON
Suffix:
Gender:M
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 E MORTEN AVE UNIT 1120
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4639
Mailing Address - Country:US
Mailing Address - Phone:801-694-5382
Mailing Address - Fax:
Practice Address - Street 1:1492 S MILL AVE STE 212
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-5664
Practice Address - Country:US
Practice Address - Phone:480-410-4128
Practice Address - Fax:480-410-4130
Is Sole Proprietor?:No
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ305255363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care