Provider Demographics
NPI:1760759823
Name:CHISMAR, RONALD BASIL (NURSE PRACTIONER)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:BASIL
Last Name:CHISMAR
Suffix:
Gender:M
Credentials:NURSE PRACTIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 MIKE PADGETT HWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-3815
Mailing Address - Country:US
Mailing Address - Phone:706-432-7893
Mailing Address - Fax:706-432-3780
Practice Address - Street 1:3421 MIKE PADGETT HWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-3815
Practice Address - Country:US
Practice Address - Phone:706-432-7893
Practice Address - Fax:706-432-3780
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-17
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN174288363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000606317BMedicaid
GAGRP2010Medicare PIN