MEDICARE: MADISON WYLIE HAWKES GAGERN

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	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1043852411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISON WYLIE HAWKES GAGERN

Provider Business Mailing Address
First Line	:	253 POE CT
Second Line	:
City	:	SEVERNA PARK
State	:	MD
Zip	:	21146-2136
Country	:	US
Telephone Number	:	301-873-2902
Fax Number	:

Provider Business Practice Location Address
First Line	:	8178 LARK BROWN RD STE 101
Second Line	:
City	:	ELKRIDGE
State	:	MD
Zip	:	21075-6438
Country	:	US
Telephone Number	:	410-646-4800
Fax Number	:

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

Provider Enumeration Date	:	10/17/2019
Last Update Date	:	05/21/2026

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