Healthcare Provider Details

I. General information

NPI: 1558119560
Provider Name (Legal Business Name): MADISON MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2024
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 HOTEL CIRCLE CT STE 200
SAN DIEGO CA
92108-3423
US

IV. Provider business mailing address

5356 E KINGS AVE
SCOTTSDALE AZ
85254-1123
US

V. Phone/Fax

Practice location:
  • Phone: 619-933-2165
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085011506
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA68382
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: