Provider Demographics
NPI:1770813479
Name:MESSFOROSH, MARYAM (PA-C)
Entity type:Individual
Prefix:MS
First Name:MARYAM
Middle Name:
Last Name:MESSFOROSH
Suffix:
Gender:F
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 1:1404 FREE RANGE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-9300
Mailing Address - Country:US
Mailing Address - Phone:410-546-0166
Mailing Address - Fax:
Practice Address - Street 1:2425 N SALISBURY BLVD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-2138
Practice Address - Country:US
Practice Address - Phone:443-944-0187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-04
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002915363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical