Provider Demographics
NPI:1366603797
Name:DETRICK, JOSHUA RYAN (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:RYAN
Last Name:DETRICK
Suffix:
Gender:M
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:PO BOX 75420
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-5420
Mailing Address - Country:US
Mailing Address - Phone:703-383-6469
Mailing Address - Fax:
Practice Address - Street 1:6355 WALKER LANE
Practice Address - Street 2:STE 202
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-3257
Practice Address - Country:US
Practice Address - Phone:703-810-5210
Practice Address - Fax:703-810-5418
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01389363A00000X
VA0110003713363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
538695Medicare PIN
VA2759180Medicare PIN