Healthcare Provider Details

I. General information

NPI: 1083376701
Provider Name (Legal Business Name): MADISEN JO AFFLECK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2021
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4403 HARRISON BLVD STE 2600
OGDEN UT
84403-3277
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-378-7450
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14219864-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: