Provider Demographics
NPI:1508017732
Name:CODLING, DEANNA M (PA)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:M
Last Name:CODLING
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:M
Other - Last Name:CODLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2401 W BELVEDERE AVE
Mailing Address - Street 2:CREDENTIALING
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5216
Mailing Address - Country:US
Mailing Address - Phone:410-601-5523
Mailing Address - Fax:410-601-8946
Practice Address - Street 1:2435 W BELVEDERE AVE
Practice Address - Street 2:SUITE 42
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5224
Practice Address - Country:US
Practice Address - Phone:410-601-5547
Practice Address - Fax:410-601-5835
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC03846363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS567Medicare PIN
MD180291Y0UMedicare PIN