Provider Demographics
NPI:1558696484
Name:NESMITH, DERRELL L (CSA)
Entity Type:Individual
Prefix:
First Name:DERRELL
Middle Name:L
Last Name:NESMITH
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3091 COBB PKWY NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-5891
Mailing Address - Country:US
Mailing Address - Phone:404-932-0637
Mailing Address - Fax:
Practice Address - Street 1:3091 COBB PKWY NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-5891
Practice Address - Country:US
Practice Address - Phone:404-932-0637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical