Provider Demographics
NPI:1659856862
Name:DURHAM, IAN MICHAEL
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:MICHAEL
Last Name:DURHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6658 CABLE CAR LN
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-3606
Mailing Address - Country:US
Mailing Address - Phone:910-620-4811
Mailing Address - Fax:
Practice Address - Street 1:1 SHIRCLIFF WAY FL 32204
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4748
Practice Address - Country:US
Practice Address - Phone:904-308-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant