Provider Demographics
NPI:1316552946
Name:FRETTO, MADELYNN LEA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:MADELYNN
Middle Name:LEA
Last Name:FRETTO
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7206 BILTMORE DR
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-4856
Mailing Address - Country:US
Mailing Address - Phone:602-663-2776
Mailing Address - Fax:
Practice Address - Street 1:101 PROSPECT ST STE 107
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5003
Practice Address - Country:US
Practice Address - Phone:732-905-8153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00573400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MP00573400OtherNEW JERSEY STATE BOARD OF MEDICAL EXAMINERS