Healthcare Provider Details

I. General information

NPI: 1730908005
Provider Name (Legal Business Name): MADELINE GRAYSTON HOFFMANN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 S LOOP RD
EDGEWOOD KY
41017-3405
US

IV. Provider business mailing address

560 S LOOP RD
EDGEWOOD KY
41017-3405
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-2663
  • Fax:
Mailing address:
  • Phone: 859-301-2663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTC082
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: