Provider Demographics
NPI:1518062793
Name:MADER, GEORGE WAYNE (RPA)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:WAYNE
Last Name:MADER
Suffix:
Gender:M
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14612 WOODSTREAM PL
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-5164
Mailing Address - Country:US
Mailing Address - Phone:502-244-3330
Mailing Address - Fax:
Practice Address - Street 1:1 AUDUBON PLAZA DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1318
Practice Address - Country:US
Practice Address - Phone:502-636-7311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT08 KY 1003363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical