Provider Demographics
NPI:1326659798
Name:ANDERSON, DEREK MILES (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:MILES
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 WOODWARD DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-7641
Mailing Address - Country:US
Mailing Address - Phone:678-858-8503
Mailing Address - Fax:
Practice Address - Street 1:545 WOODWARD DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-7641
Practice Address - Country:US
Practice Address - Phone:678-858-8503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN128292363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner