Provider Demographics
NPI:1790818383
Name:MADDOCK, MEGAN ANNETTE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:ANNETTE
Last Name:MADDOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1560 E CHEVY CHASE DR STE 320
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4140
Mailing Address - Country:US
Mailing Address - Phone:818-243-2222
Mailing Address - Fax:818-243-2221
Practice Address - Street 1:1560 E CHEVY CHASE DR STE 320
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4140
Practice Address - Country:US
Practice Address - Phone:818-243-2222
Practice Address - Fax:818-243-2221
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 17141363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical