Provider Demographics
NPI:1598053225
Name:WASHBURN, DEBORAH MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:MICHELLE
Last Name:WASHBURN
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 1:2124 14TH ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-4040
Mailing Address - Country:US
Mailing Address - Phone:601-703-3480
Mailing Address - Fax:601-703-0124
Practice Address - Street 1:1056 HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-9121
Practice Address - Country:US
Practice Address - Phone:601-656-8545
Practice Address - Fax:601-656-3985
Is Sole Proprietor?:No
Enumeration Date:2011-07-15
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00152363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04774800Medicaid