Healthcare Provider Details

I. General information

NPI: 1548124266
Provider Name (Legal Business Name): MADISON LANE WELLEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 E BROADWAY
COLUMBIA MO
65201
US

IV. Provider business mailing address

3301 FAIRWAY DR
HIGHLAND IL
62249-2804
US

V. Phone/Fax

Practice location:
  • Phone: 573-442-2211
  • Fax:
Mailing address:
  • Phone: 618-792-8102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: