Healthcare Provider Details

I. General information

NPI: 1710709100
Provider Name (Legal Business Name): MADISON HOLM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 4TH AVE S
WISHEK ND
58495-7527
US

IV. Provider business mailing address

1007 4TH AVE S
WISHEK ND
58495-7527
US

V. Phone/Fax

Practice location:
  • Phone: 701-452-2326
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPAC1122
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: