Healthcare Provider Details

I. General information

NPI: 1114369089
Provider Name (Legal Business Name): KATIE L MADDEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATIE INGERSON

II. Dates (important events)

Enumeration Date: 07/22/2013
Last Update Date: 10/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 PRATHER AVE SUITE 100, 200, & 400
JAMESTOWN NY
14701-6820
US

IV. Provider business mailing address

95 E CHAUTAUQUA ST
MAYVILLE NY
14757-1017
US

V. Phone/Fax

Practice location:
  • Phone: 716-338-0022
  • Fax: 716-338-1567
Mailing address:
  • Phone: 716-753-7107
  • Fax: 716-753-5367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number016751
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: