Provider Demographics
NPI:1083310957
Name:SONG, PAIGE (PA-C)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:SONG
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 1:12709 HALL SHOP RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:MD
Mailing Address - Zip Code:20777-9547
Mailing Address - Country:US
Mailing Address - Phone:301-704-0215
Mailing Address - Fax:
Practice Address - Street 1:900 S CATON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5201
Practice Address - Country:US
Practice Address - Phone:667-234-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC08797363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty