Provider Demographics
NPI:1073598645
Name:DERAMUS, LEONARD DAVEY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:LEONARD
Middle Name:DAVEY
Last Name:DERAMUS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 CARLTON ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30602-1503
Mailing Address - Country:US
Mailing Address - Phone:706-542-8609
Mailing Address - Fax:
Practice Address - Street 1:55 CARLTON ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30602-1503
Practice Address - Country:US
Practice Address - Phone:706-542-8609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001541363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000261093BMedicaid
GA97BBCBRMedicare ID - Type Unspecified