Provider Demographics
NPI:1003897661
Name:MADSEN, BRENT L (PA-C)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:L
Last Name:MADSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:NE
Mailing Address - Zip Code:68370-2019
Mailing Address - Country:US
Mailing Address - Phone:402-768-7203
Mailing Address - Fax:402-768-4669
Practice Address - Street 1:120 PARK AVE
Practice Address - Street 2:
Practice Address - City:HEBRON
Practice Address - State:NE
Practice Address - Zip Code:68370
Practice Address - Country:US
Practice Address - Phone:402-768-7203
Practice Address - Fax:402-768-4669
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE631207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE508944155Medicaid
NER81931Medicare UPIN