Provider Demographics
NPI:1790116903
Name:VERTIN, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:VERTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1054 TEXAN TRL
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3784
Mailing Address - Country:US
Mailing Address - Phone:817-865-3407
Mailing Address - Fax:
Practice Address - Street 1:400 S CLARK ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-2328
Practice Address - Country:US
Practice Address - Phone:406-595-1284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-13
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT27642363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant