Provider Demographics
NPI:1386074474
Name:DEREFAKA, GEORGE (CRNA)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:DEREFAKA
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 1:3601 W COMMERCIAL BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3300
Mailing Address - Country:US
Mailing Address - Phone:954-703-2931
Mailing Address - Fax:954-585-0297
Practice Address - Street 1:3601 W COMMERCIAL BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-3300
Practice Address - Country:US
Practice Address - Phone:954-703-2931
Practice Address - Fax:954-585-0297
Is Sole Proprietor?:No
Enumeration Date:2013-11-26
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024028590367500000X
FLRN9274231367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered