Healthcare Provider Details

I. General information

NPI: 1285999433
Provider Name (Legal Business Name): MEAGEN STURDIVANT MADDOX PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2012
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3493 VETERANS DR N SUITE C
HUNTINGDON TN
38344-6227
US

IV. Provider business mailing address

PO BOX 465
HUNTINGDON TN
38344-0465
US

V. Phone/Fax

Practice location:
  • Phone: 731-986-2933
  • Fax: 731-986-2938
Mailing address:
  • Phone: 731-986-2933
  • Fax: 731-986-2938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2167
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: