Healthcare Provider Details

I. General information

NPI: 1649744178
Provider Name (Legal Business Name): MADISON ANN MINNICK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADISON ANN VITELLI

II. Dates (important events)

Enumeration Date: 01/17/2019
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SPRUCE ST
PHILADELPHIA PA
19104-4269
US

IV. Provider business mailing address

1671 CROOKED OAK DR
LANCASTER PA
17601-4269
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-3487
  • Fax: 215-349-5534
Mailing address:
  • Phone: 717-569-5331
  • Fax: 717-569-4210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00603200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA060311
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: