Healthcare Provider Details

I. General information

NPI: 1548027444
Provider Name (Legal Business Name): MADELYN C WEBER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2024
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 MARKETPOINTE DR STE 100
BLOOMINGTON MN
55435-5435
US

IV. Provider business mailing address

4300 MARKETPOINTE DR STE 100
BLOOMINGTON MN
55435-5435
US

V. Phone/Fax

Practice location:
  • Phone: 945-835-9880
  • Fax: 952-835-4403
Mailing address:
  • Phone: 945-835-9880
  • Fax: 952-835-4403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15507
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: