Provider Demographics
NPI:1225707466
Name:DURHAM, MADISON D (PA)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:D
Last Name:DURHAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:D
Other - Last Name:VERRALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:501 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3550
Mailing Address - Country:US
Mailing Address - Phone:509-853-1082
Mailing Address - Fax:509-853-1082
Practice Address - Street 1:38 HERITAGE CT
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-3616
Practice Address - Country:US
Practice Address - Phone:716-986-9199
Practice Address - Fax:716-304-1044
Is Sole Proprietor?:No
Enumeration Date:2021-09-10
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WABG61193134363A00000X
WAPA61187385363A00000X
NY031185363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2188015Medicaid