Provider Demographics
NPI:1548785850
Name:BAUCUM, MADELYN A (PA)
Entity Type:Individual
Prefix:
First Name:MADELYN
Middle Name:A
Last Name:BAUCUM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-0247
Mailing Address - Country:US
Mailing Address - Phone:601-399-6169
Mailing Address - Fax:601-399-6262
Practice Address - Street 1:1220 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4355
Practice Address - Country:US
Practice Address - Phone:601-426-4000
Practice Address - Fax:601-426-4105
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00335363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant