Healthcare Provider Details

I. General information

NPI: 1407680440
Provider Name (Legal Business Name): EMILY GRACE MADSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9630 GROVE CIR N STE 200
MAPLE GROVE MN
55369-3492
US

IV. Provider business mailing address

3500 AMERICAN BLVD W STE 300
BLOOMINGTON MN
55431-4442
US

V. Phone/Fax

Practice location:
  • Phone: 763-520-7870
  • Fax: 763-520-7580
Mailing address:
  • Phone: 952-512-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15043
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: