MEDICARE: MS. DONELL DAWN DEREMER PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	C0001579	MD

General Provider Information

NPI Number	:	1205944634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DONELL DAWN DEREMER PA-C

Provider Business Mailing Address
First Line	:	629 BEAVER RUIN RD NW
Second Line	:	SUITE B
City	:	LILBURN
State	:	GA
Zip	:	30047-3468
Country	:	US
Telephone Number	:	770-921-4300
Fax Number	:

Provider Business Practice Location Address
First Line	:	902 WASHINGTON RD
Second Line	:	SUITE E
City	:	WESTMINSTER
State	:	MD
Zip	:	21157-5832
Country	:	US
Telephone Number	:	410-876-0286
Fax Number	:	410-876-0634

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/27/2006
Last Update Date	:	09/23/2014

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