Healthcare Provider Details

I. General information

NPI: 1154169365
Provider Name (Legal Business Name): MADELEINE CORRADO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADELEINE GIBSON PA-C

II. Dates (important events)

Enumeration Date: 07/20/2024
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7503 SURRATTS RD
CLINTON MD
20735-3358
US

IV. Provider business mailing address

7503 SURRATTS RD
CLINTON MD
20735-3358
US

V. Phone/Fax

Practice location:
  • Phone: 410-772-6500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110010177
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: