Healthcare Provider Details

I. General information

NPI: 1376267534
Provider Name (Legal Business Name): MADISON MARIE MCKAMEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2022
Last Update Date: 11/08/2025
Certification Date: 11/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10105 BANBURRY CROSS DR STE 170
LAS VEGAS NV
89144-6647
US

IV. Provider business mailing address

10105 BANBURRY CROSS DR STE 170
LAS VEGAS NV
89144-6647
US

V. Phone/Fax

Practice location:
  • Phone: 702-765-5437
  • Fax:
Mailing address:
  • Phone: 702-765-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1204283
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: