Provider Demographics
NPI:1265042824
Name:MOGENSEN, MADORA DEON (CNM)
Entity Type:Individual
Prefix:
First Name:MADORA
Middle Name:DEON
Last Name:MOGENSEN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:MADORA
Other - Middle Name:DEON
Other - Last Name:WATERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:600 E GENESEE ST STE 323
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-3108
Mailing Address - Country:US
Mailing Address - Phone:315-426-1100
Mailing Address - Fax:315-426-1153
Practice Address - Street 1:600 E GENESEE ST STE 323
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3108
Practice Address - Country:US
Practice Address - Phone:315-426-1100
Practice Address - Fax:315-426-1153
Is Sole Proprietor?:No
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF001985176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife