MEDICARE: MADISON D DURHAM PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant
2	363A00000X	Physician Assistant	BG61193134	WA
3	363A00000X	Physician Assistant	PA61187385	WA
4	363A00000X	Physician Assistant	031185	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225707466
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISON D DURHAM PA

Provider Business Mailing Address
First Line	:	501 S 5TH AVE
Second Line	:
City	:	YAKIMA
State	:	WA
Zip	:	98902-3550
Country	:	US
Telephone Number	:	509-853-1082
Fax Number	:	509-853-1082

Provider Business Practice Location Address
First Line	:	38 HERITAGE CT
Second Line	:
City	:	LOCKPORT
State	:	NY
Zip	:	14094-3616
Country	:	US
Telephone Number	:	716-986-9199
Fax Number	:	716-304-1044

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2021
Last Update Date	:	01/29/2024

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Directions to “ MADISON D DURHAM PA” Practice Location

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