Provider Demographics
NPI:1124378492
Name:FORD, DUSTIN R (PA-C)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:R
Last Name:FORD
Suffix:
Gender:M
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 1:170 TAYLOR STATION RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-4491
Mailing Address - Country:US
Mailing Address - Phone:614-545-7900
Mailing Address - Fax:614-545-7901
Practice Address - Street 1:170 TAYLOR STATION RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-4491
Practice Address - Country:US
Practice Address - Phone:614-545-7900
Practice Address - Fax:614-545-7901
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003576363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant