Healthcare Provider Details

I. General information

NPI: 1245916592
Provider Name (Legal Business Name): MADISON WANYO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 MAIN ST
PAWTUCKET RI
02860-7825
US

IV. Provider business mailing address

1145 MAIN ST
PAWTUCKET RI
02860-7825
US

V. Phone/Fax

Practice location:
  • Phone: 401-722-0081
  • Fax: 401-312-0318
Mailing address:
  • Phone: 401-722-0081
  • Fax: 401-312-0318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA01619
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: