MEDICARE: MARTIN MADRIGAL PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA17142	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA17142	OTHER	CA	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1043371636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTIN MADRIGAL PA-C

Provider Business Mailing Address
First Line	:	5404 MORENO ST
Second Line	:	SUITE N
City	:	MONTCLAIR
State	:	CA
Zip	:	91763-1667
Country	:	US
Telephone Number	:	909-949-4400
Fax Number	:	909-949-4441

Provider Business Practice Location Address
First Line	:	5404 MORENO ST
Second Line	:	SUITE N
City	:	MONTCLAIR
State	:	CA
Zip	:	91763-1667
Country	:	US
Telephone Number	:	909-949-4400
Fax Number	:	909-949-4441

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	12/15/2014

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Directions to “ MARTIN MADRIGAL PA-C” Practice Location

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