Healthcare Provider Details

I. General information

NPI: 1457080418
Provider Name (Legal Business Name): MADISON ALEXANDRA REDWINE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 08/05/2024
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 N CHURCH ST
GREENSBORO NC
27401-1007
US

IV. Provider business mailing address

214 BELLEMEADE ST APT 304
GREENSBORO NC
27401-2572
US

V. Phone/Fax

Practice location:
  • Phone: 336-207-7005
  • Fax:
Mailing address:
  • Phone: 404-735-4956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-12313
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: