Provider Demographics
NPI:1265312334
Name:IRVIN, EBONY (CCMA)
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:IRVIN
Suffix:
Gender:F
Credentials:CCMA
Other - Prefix:MRS
Other - First Name:EBONY
Other - Middle Name:
Other - Last Name:GRIFFIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CCMA
Mailing Address - Street 1:1258 HOLLAND RD
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-6313
Mailing Address - Country:US
Mailing Address - Phone:877-848-9810
Mailing Address - Fax:
Practice Address - Street 1:1258 HOLLAND RD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-6313
Practice Address - Country:US
Practice Address - Phone:877-848-9810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAM5Y3S8K8363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical