Provider Demographics
NPI:1407312598
Name:BURKS, MADISON ASHLEY (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:MADISON
Middle Name:ASHLEY
Last Name:BURKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 DULLES DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-3718
Mailing Address - Country:US
Mailing Address - Phone:337-991-9276
Mailing Address - Fax:
Practice Address - Street 1:2300 ANDOVER CT
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72227-3987
Practice Address - Country:US
Practice Address - Phone:501-904-5159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-901363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program