Provider Demographics
NPI:1376768358
Name:MADRONE, GABRIEL ISA (MA)
Entity Type:Individual
Prefix:MS
First Name:GABRIEL
Middle Name:ISA
Last Name:MADRONE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 271
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047-0271
Mailing Address - Country:US
Mailing Address - Phone:928-288-8300
Mailing Address - Fax:928-288-8393
Practice Address - Street 1:800 N APACHE AVE
Practice Address - Street 2:1100 COLORADO AVE
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-3819
Practice Address - Country:US
Practice Address - Phone:928-288-8300
Practice Address - Fax:928-288-8393
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ125727Medicaid