Provider Demographics
NPI:1427002310
Name:NOVARA, DEREK J (CRNA)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:J
Last Name:NOVARA
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 1:18100 OAKWOOD BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4071
Mailing Address - Country:US
Mailing Address - Phone:313-253-2000
Mailing Address - Fax:
Practice Address - Street 1:18100 OAKWOOD BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4071
Practice Address - Country:US
Practice Address - Phone:313-253-2000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704212578367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4835527Medicaid
MI4394656Medicaid