Healthcare Provider Details

I. General information

NPI: 1013980184
Provider Name (Legal Business Name): DEREK AARON LAFONT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3696 WHEELER RD
AUGUSTA GA
30909-6520
US

IV. Provider business mailing address

3696 WHEELER RD
AUGUSTA GA
30909-6520
US

V. Phone/Fax

Practice location:
  • Phone: 706-736-1830
  • Fax: 706-650-7553
Mailing address:
  • Phone: 706-736-1830
  • Fax: 706-650-7553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004721
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: