Healthcare Provider Details

I. General information

NPI: 1265312334
Provider Name (Legal Business Name): EBONY IRVIN CCMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EBONY GRIFFIN CCMA

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1258 HOLLAND RD
SUFFOLK VA
23434-6313
US

IV. Provider business mailing address

1258 HOLLAND RD
SUFFOLK VA
23434-6313
US

V. Phone/Fax

Practice location:
  • Phone: 877-848-9810
  • Fax:
Mailing address:
  • Phone: 877-848-9810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberM5Y3S8K8
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: