Provider Demographics
NPI:1598486326
Name:KOON, MADISON ALYSE (PA-C)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:ALYSE
Last Name:KOON
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 1:1426 S LAPEER RD
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360
Mailing Address - Country:US
Mailing Address - Phone:248-693-0543
Mailing Address - Fax:248-693-3683
Practice Address - Street 1:1428 S LAPEER RD
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1437
Practice Address - Country:US
Practice Address - Phone:248-693-0543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-09
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011346363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant