Provider Demographics
NPI:1962281162
Name:DERHAM, MADELINE ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:ROSE
Last Name:DERHAM
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 1:261 MOORE RD
Mailing Address - Street 2:
Mailing Address - City:DOWNINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19335-4509
Mailing Address - Country:US
Mailing Address - Phone:610-241-5406
Mailing Address - Fax:
Practice Address - Street 1:595 W STATE ST
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18901-2554
Practice Address - Country:US
Practice Address - Phone:215-345-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA006669363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant