Provider Demographics
NPI:1346461803
Name:BAYHAM, DEBRA GREGORY (PA)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:GREGORY
Last Name:BAYHAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 E VIRGINIA AVE
Mailing Address - Street 2:220
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1206
Mailing Address - Country:US
Mailing Address - Phone:602-258-9955
Mailing Address - Fax:602-258-9933
Practice Address - Street 1:333 E VIRGINIA AVE
Practice Address - Street 2:220
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1206
Practice Address - Country:US
Practice Address - Phone:602-258-9955
Practice Address - Fax:602-258-9933
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2270363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ596554Medicaid
AZ44955Medicare UPIN