Provider Demographics
NPI:1508424102
Name:DEBOL, MADELINE NICOLE (PA)
Entity Type:Individual
Prefix:MRS
First Name:MADELINE
Middle Name:NICOLE
Last Name:DEBOL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:MADELINE
Other - Middle Name:NICOLE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7183 SUNSHINE DR
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55346-2755
Mailing Address - Country:US
Mailing Address - Phone:952-270-2272
Mailing Address - Fax:
Practice Address - Street 1:500 HARVARD ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0363
Practice Address - Country:US
Practice Address - Phone:952-270-2272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant