Provider Demographics
NPI:1083017271
Name:MADISON, BANEE (PA)
Entity Type:Individual
Prefix:
First Name:BANEE
Middle Name:
Last Name:MADISON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 AMBASSADOR CAFFERY PKWY
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6902
Mailing Address - Country:US
Mailing Address - Phone:337-561-9100
Mailing Address - Fax:
Practice Address - Street 1:4600 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6902
Practice Address - Country:US
Practice Address - Phone:337-561-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-01
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200759363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant