Healthcare Provider Details

I. General information

NPI: 1407805757
Provider Name (Legal Business Name): MARK J. MADSEN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 E BRIGGSMORE AVE
MODESTO CA
95355-2707
US

IV. Provider business mailing address

600 COFFEE RD
MODESTO CA
95355-4201
US

V. Phone/Fax

Practice location:
  • Phone: 209-550-4725
  • Fax:
Mailing address:
  • Phone: 209-521-6097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10310
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: