Provider Demographics
NPI:1023565199
Name:DUBOIS, DEREK AUSTIN (NP)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:AUSTIN
Last Name:DUBOIS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 TOWER RD NE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-9404
Mailing Address - Country:US
Mailing Address - Phone:770-427-5717
Mailing Address - Fax:770-514-5040
Practice Address - Street 1:300 TOWER RD NE
Practice Address - Street 2:SUITE 200
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-9404
Practice Address - Country:US
Practice Address - Phone:770-427-5717
Practice Address - Fax:770-514-5040
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN217341363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily