Healthcare Provider Details

I. General information

NPI: 1750784617
Provider Name (Legal Business Name): ROMAN K MADSEN PA-S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2014
Last Update Date: 12/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 N PLAZA DR
APACHE JUNCTION AZ
85120-5501
US

IV. Provider business mailing address

1185 W 1140 N
PROVO UT
84604-3011
US

V. Phone/Fax

Practice location:
  • Phone: 480-278-3374
  • Fax:
Mailing address:
  • Phone: 480-278-3374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6220
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: