Provider Demographics
NPI:1053840231
Name:DURHAM, JOANNA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:MARIE
Last Name:DURHAM
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 1:1505 HEATHER HILL LN
Mailing Address - Street 2:
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030-1632
Mailing Address - Country:US
Mailing Address - Phone:443-415-2849
Mailing Address - Fax:
Practice Address - Street 1:1800 ORLEANS ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0010
Practice Address - Country:US
Practice Address - Phone:443-415-2849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC06498363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant