Provider Demographics
NPI:1295371458
Name:GOUDY, MADISON E (PA-C, MSPAS)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:E
Last Name:GOUDY
Suffix:
Gender:F
Credentials:PA-C, MSPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 WILTON WAY
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-9212
Mailing Address - Country:US
Mailing Address - Phone:610-741-4259
Mailing Address - Fax:
Practice Address - Street 1:875 AAA BLVD STE C
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-3624
Practice Address - Country:US
Practice Address - Phone:302-918-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0001372363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC5-0001372OtherLICENSE NUMBER