Healthcare Provider Details

I. General information

NPI: 1235699158
Provider Name (Legal Business Name): MADISON PAIGE TEDROW PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

571 S ALLEN RD
FLAT ROCK NC
28731-9447
US

IV. Provider business mailing address

571 S ALLEN RD
FLAT ROCK NC
28731-9447
US

V. Phone/Fax

Practice location:
  • Phone: 828-692-6178
  • Fax: 828-692-2365
Mailing address:
  • Phone: 828-692-6178
  • Fax: 828-692-2365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-08948
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: