Healthcare Provider Details

I. General information

NPI: 1396488748
Provider Name (Legal Business Name): MADISON KAYE OAKES-DUTKEVITCH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2022
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8459 COLERAIN AVE
CINCINNATI OH
45239-3938
US

IV. Provider business mailing address

1430 OAK CT STE 100
BEAVERCREEK OH
45430-1064
US

V. Phone/Fax

Practice location:
  • Phone: 434-944-0053
  • Fax:
Mailing address:
  • Phone: 937-404-1101
  • Fax: 937-404-1210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.007821RX
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: