Provider Demographics
NPI:1093452849
Name:BREWTON, MADISON (PA)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:BREWTON
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 1:8080 BLUEBONNET BLVD STE 1000
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-7827
Mailing Address - Country:US
Mailing Address - Phone:225-408-6633
Mailing Address - Fax:225-408-7965
Practice Address - Street 1:8080 BLUEBONNET BLVD STE 3100
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810
Practice Address - Country:US
Practice Address - Phone:225-924-2424
Practice Address - Fax:225-408-7854
Is Sole Proprietor?:No
Enumeration Date:2022-05-13
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA339178363A00000X, 363A00000X
TXPA15926207XX0005X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty