Healthcare Provider Details

I. General information

NPI: 1497674980
Provider Name (Legal Business Name): MADISYN CHURN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 ELM AVE SE
ROANOKE VA
24013-2222
US

IV. Provider business mailing address

101 ELM AVE SE
ROANOKE VA
24013-2222
US

V. Phone/Fax

Practice location:
  • Phone: 540-352-7061
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: