=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477120426
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADISON MARIE MASTERS PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2021
-----------------------------------------------------
Last Update Date | 06/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 S LAFAYETTE ST
-----------------------------------------------------
City | SOUTH LYON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48178-1404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 947-348-1176
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4235 SECOR RD
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43623-4299
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-473-3561
-----------------------------------------------------
Fax | 419-479-5593
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------