Healthcare Provider Details

I. General information

NPI: 1043833965
Provider Name (Legal Business Name): MADISEN DEAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 05/27/2020
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24276 AIRPORT RD
EAGLE BUTTE SD
57625-8021
US

IV. Provider business mailing address

24276 AIRPORT RD
EAGLE BUTTE SD
57625-8021
US

V. Phone/Fax

Practice location:
  • Phone: 605-645-0063
  • Fax:
Mailing address:
  • Phone: 605-645-0063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberR052076
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: