Provider Demographics
NPI:1700406220
Name:MADDEN, DEREK RICHARD (PA-C)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:RICHARD
Last Name:MADDEN
Suffix:
Gender:M
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 1:800 WASHINGTON STREET
Mailing Address - Street 2:DEPARTMENT OF ORTHOPEDICS
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111
Mailing Address - Country:US
Mailing Address - Phone:617-636-7846
Mailing Address - Fax:
Practice Address - Street 1:800 WASHINGTON ST
Practice Address - Street 2:DEPARTMENT OF ORTHOPAEDIC SURGERY
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111
Practice Address - Country:US
Practice Address - Phone:617-636-7846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-24
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA7905363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant