Healthcare Provider Details

I. General information

NPI: 1629908405
Provider Name (Legal Business Name): ERIN ALYSSA MADYUN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 BOTTINEAU BLVD STE 100
CRYSTAL MN
55429-3184
US

IV. Provider business mailing address

6700 PIONEER TRL
LORETTO MN
55357-9691
US

V. Phone/Fax

Practice location:
  • Phone: 763-504-6500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number15766
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: