Provider Demographics
NPI:1114514569
Name:ELLERBROCK, MADELINE (PA)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:ELLERBROCK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5715
Mailing Address - Fax:540-224-5684
Practice Address - Street 1:1906 BELLEVIEW AVE SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1838
Practice Address - Country:US
Practice Address - Phone:540-981-7000
Practice Address - Fax:540-853-0931
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2022-08-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0110008422363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant