Provider Demographics
NPI:1114463437
Name:ANDERSON, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33
Mailing Address - Street 2:
Mailing Address - City:CHIGNIK
Mailing Address - State:AK
Mailing Address - Zip Code:99564-0033
Mailing Address - Country:US
Mailing Address - Phone:907-512-7107
Mailing Address - Fax:
Practice Address - Street 1:6000 KANAKANAK RD.
Practice Address - Street 2:
Practice Address - City:DILLINGHAM
Practice Address - State:AK
Practice Address - Zip Code:99576
Practice Address - Country:US
Practice Address - Phone:907-512-7107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK16-1396-III172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker