Healthcare Provider Details

I. General information

NPI: 1457977969
Provider Name (Legal Business Name): KATIE LYNN MADLEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2020
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5550 MERRICK RD
MASSAPEQUA NY
11758-6238
US

IV. Provider business mailing address

5550 MERRICK RD
MASSAPEQUA NY
11758-6238
US

V. Phone/Fax

Practice location:
  • Phone: 631-673-3233
  • Fax:
Mailing address:
  • Phone: 631-673-3233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number025075
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: