Provider Demographics
NPI:1770822348
Name:STANFORD, PETER MALCOLM (PA-C)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:MALCOLM
Last Name:STANFORD
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 1:301 RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21629-1243
Mailing Address - Country:US
Mailing Address - Phone:410-479-4306
Mailing Address - Fax:410-479-1714
Practice Address - Street 1:316 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:MD
Practice Address - Zip Code:21636-1126
Practice Address - Country:US
Practice Address - Phone:410-634-2380
Practice Address - Fax:410-482-7488
Is Sole Proprietor?:No
Enumeration Date:2013-02-02
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC04049363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical