Healthcare Provider Details

I. General information

NPI: 1730709775
Provider Name (Legal Business Name): MADELINE ELIZABETH MARKSTROM PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADELINE ELIZABETH LUMMIS

II. Dates (important events)

Enumeration Date: 04/20/2020
Last Update Date: 08/25/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6620 COYLE AVE STE 303
CARMICHAEL CA
95608-6337
US

IV. Provider business mailing address

660 OCEAN AVE APT 110
REVERE MA
02151-1285
US

V. Phone/Fax

Practice location:
  • Phone: 916-965-4000
  • Fax:
Mailing address:
  • Phone: 916-704-0167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: