Provider Demographics
NPI:1467164962
Name:GLYNN, MADISON TAYLOR
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:TAYLOR
Last Name:GLYNN
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 1:1940 PAVILION DR APT 417
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-5591
Mailing Address - Country:US
Mailing Address - Phone:757-503-0251
Mailing Address - Fax:
Practice Address - Street 1:6160 KEMPSVILLE CIR STE 200B
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3945
Practice Address - Country:US
Practice Address - Phone:757-321-3300
Practice Address - Fax:757-321-3330
Is Sole Proprietor?:No
Enumeration Date:2022-12-16
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009369363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant