Provider Demographics
NPI:1386669307
Name:MADSEN, LEESA M (PA)
Entity Type:Individual
Prefix:
First Name:LEESA
Middle Name:M
Last Name:MADSEN
Suffix:
Gender:F
Credentials:PA
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 3650
Mailing Address - Street 2:
Mailing Address - City:MERRIFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22116-3650
Mailing Address - Country:US
Mailing Address - Phone:703-698-4483
Mailing Address - Fax:703-573-0880
Practice Address - Street 1:2722 MERRILEE DR
Practice Address - Street 2:SUITE 230
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4400
Practice Address - Country:US
Practice Address - Phone:703-698-4483
Practice Address - Fax:703-573-0880
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01108407902085B0100X, 2085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101317452Medicaid
VA259998OtherKAISER PERMANENTE
VA010317274Medicaid
VA0101305055Medicaid
VA0101310791Medicaid
VA0101316774Medicaid
VA0101317347Medicaid
VA010316855Medicaid
VA010317452Medicaid
VA010304989Medicaid
VA010316910Medicaid
VA010317401Medicaid
VA010316847Medicaid
VA010316936Medicaid
VA010317240Medicaid
VA010317312Medicaid
VA010317428Medicaid
VA0101317371Medicaid
VA010316839Medicaid
VA010316804Medicaid
VA010316839Medicaid
VA010317312Medicaid
VA0101310791Medicaid