Provider Demographics
NPI:1205944634
Name:DEREMER, DONELL DAWN (PA-C)
Entity type:Individual
Prefix:MS
First Name:DONELL
Middle Name:DAWN
Last Name:DEREMER
Suffix:
Gender:F
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 1:629 BEAVER RUIN RD NW
Mailing Address - Street 2:SUITE B
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3468
Mailing Address - Country:US
Mailing Address - Phone:770-921-4300
Mailing Address - Fax:
Practice Address - Street 1:902 WASHINGTON RD
Practice Address - Street 2:SUITE E
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-5832
Practice Address - Country:US
Practice Address - Phone:410-876-0286
Practice Address - Fax:410-876-0634
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001579363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD361815Medicare PIN