Provider Demographics
NPI:1194897710
Name:DEROSSO, DAVID (CRNA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:DEROSSO
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:598 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-3357
Mailing Address - Country:US
Mailing Address - Phone:478-633-6706
Mailing Address - Fax:478-633-5384
Practice Address - Street 1:1499 FAIR RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-1683
Practice Address - Country:US
Practice Address - Phone:704-662-5544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN135847367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000932236BOtherPEACHSTATE
GA000932236BMedicaid
GA344303OtherWELLCARE
GAP00115347OtherRAILROAD MEDICARE
GA344303OtherWELLCARE
GAP46686Medicare UPIN