Provider Demographics
NPI:1376267534
Name:LAMB, MADISON MARIE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:MARIE
Last Name:LAMB
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 1:8760 W PATRICK LN UNIT 2193
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5318
Mailing Address - Country:US
Mailing Address - Phone:612-281-0638
Mailing Address - Fax:
Practice Address - Street 1:10105 BANBURRY CROSS DR STE 170
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-6647
Practice Address - Country:US
Practice Address - Phone:702-765-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-30
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NV1204283363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program