Provider Demographics
NPI:1609327816
Name:NICKERSON, MADELYN M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MADELYN
Middle Name:M
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MADELYN
Other - Middle Name:MCNAMARA
Other - Last Name:SCRENOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6801 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-6844
Mailing Address - Country:US
Mailing Address - Phone:727-822-3238
Mailing Address - Fax:813-635-2613
Practice Address - Street 1:6801 4TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-6844
Practice Address - Country:US
Practice Address - Phone:727-822-3238
Practice Address - Fax:727-823-1278
Is Sole Proprietor?:No
Enumeration Date:2016-10-23
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109804363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019646400Medicaid