Provider Demographics
NPI:1417409103
Name:GOBBELL, MADISON (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MADISON
Middle Name:
Last Name:GOBBELL
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 1:516 E 35TH ST
Mailing Address - Street 2:APT 1O
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-1164
Mailing Address - Country:US
Mailing Address - Phone:865-679-6234
Mailing Address - Fax:
Practice Address - Street 1:1524 E MOREHEAD STREET
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1164
Practice Address - Country:US
Practice Address - Phone:704-343-7018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06829363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant