Provider Demographics
NPI:1639477409
Name:DAKERMANDJI, JOSEPH GEORGES (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:GEORGES
Last Name:DAKERMANDJI
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:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-4649
Mailing Address - Fax:336-716-9916
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-6338
Practice Address - Country:US
Practice Address - Phone:336-716-4649
Practice Address - Fax:336-716-9916
Is Sole Proprietor?:No
Enumeration Date:2011-03-03
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2313363A00000X
VA0110003479363A00000X
NC0010-12289363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2199PAMedicaid
SCSC57567951Medicare UPIN