Healthcare Provider Details

I. General information

NPI: 1699524876
Provider Name (Legal Business Name): MADISON FOLSOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10710 N TORREY PINES RD
LA JOLLA CA
92037-1035
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 858-554-8984
  • Fax:
Mailing address:
  • Phone: 858-554-8984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA64808
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: