Provider Demographics
NPI:1275615197
Name:DERAMUS, LEONIE HORSTER (MD)
Entity Type:Individual
Prefix:DR
First Name:LEONIE
Middle Name:HORSTER
Last Name:DERAMUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1867 AIRPORT WAY
Mailing Address - Street 2:STE 130B
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4056
Mailing Address - Country:US
Mailing Address - Phone:907-452-2178
Mailing Address - Fax:907-452-3524
Practice Address - Street 1:1867 AIRPORT WAY
Practice Address - Street 2:STE 130B
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4056
Practice Address - Country:US
Practice Address - Phone:907-452-2178
Practice Address - Fax:907-452-3524
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK2372207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD2732Medicaid
AK150529Medicare PIN
AKMD2732Medicaid