Healthcare Provider Details

I. General information

NPI: 1235781295
Provider Name (Legal Business Name): MADISON PETERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 LIMELIGHT AVE STE 100
CASTLE ROCK CO
80109-8034
US

IV. Provider business mailing address

4350 LIMELIGHT AVE STE 100
CASTLE ROCK CO
80109-8034
US

V. Phone/Fax

Practice location:
  • Phone: 720-455-3775
  • Fax: 720-455-3776
Mailing address:
  • Phone: 720-455-3775
  • Fax: 720-455-3776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.5821
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: