Provider Demographics
NPI:1598726978
Name:BANHAM, IVONA M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:IVONA
Middle Name:M
Last Name:BANHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:IWONA
Other - Middle Name:M
Other - Last Name:BANGHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2700 QUARRY LAKE DR STE 300
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2700 QUARRY LAKE DR STE 300
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3746
Practice Address - Country:US
Practice Address - Phone:410-768-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0000856363A00000X
MDC00856363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP00141770OtherR/R MEDICARE PROVIDER #
MDCN6601OtherR/R MEDICARE GROUP #
MDCN6601OtherR/R MEDICARE GROUP #
MDKL19I460Medicare PIN
MDKL09K591Medicare PIN