1679654693 NPI number — MRS. DEBORAH WARE FORDHAM PA-C

Table of content: MRS. DEBORAH WARE FORDHAM PA-C (NPI 1679654693)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679654693 NPI number — MRS. DEBORAH WARE FORDHAM PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORDHAM
Provider First Name:
DEBORAH
Provider Middle Name:
WARE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679654693
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
RR 1 BOX 60-1
Provider Second Line Business Mailing Address:
1127 REBIE ROAD
Provider Business Mailing Address City Name:
CHESTER
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31012-9538
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-358-4370
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1826 VETERANS BOULEVARD
Provider Second Line Business Practice Location Address:
CARL VINSON VA MEDICAL CENTER
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-272-1210
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  002877 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1032004 . This is a "NATIONAL NCCPA NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 002877 . This is a "PA-C NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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