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NPI Code Detail

MEDICARE: MS. MADELYN BROOKE BOGGS PA

MEDICARE: MS. MADELYN BROOKE BOGGS PA
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
1363A00000XPhysician Assistant10003440AIN

General Provider Information

NPI Number : 1124796792
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. MADELYN BROOKE BOGGS PA
Provider Business Mailing Address
First Line : 11109 PARKVIEW PLAZA DR # 117
Second Line :
City : FORT WAYNE
State : IN
Zip : 46845-1701
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 11141 PARKVIEW PLAZA DR STE 320
Second Line :
City : FORT WAYNE
State : IN
Zip : 46845-1714
Country : US
Telephone Number : 260-425-5400
Fax Number : 260-425-5417
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/31/2021
Last Update Date : 12/12/2025

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