Provider Demographics
NPI:1841229937
Name:MADERA, NICOLE REIS (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:REIS
Last Name:MADERA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:A
Other - Last Name:REIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:14239 W BELL RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-2469
Mailing Address - Country:US
Mailing Address - Phone:623-544-7755
Mailing Address - Fax:623-544-8665
Practice Address - Street 1:6230 W UNION HILLS DR
Practice Address - Street 2:SUITE 100
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308
Practice Address - Country:US
Practice Address - Phone:623-376-7600
Practice Address - Fax:623-376-0229
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103458363A00000X
AZ3638363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ57743Medicare UPIN
FLU6505ZMedicare ID - Type Unspecified
AZWCKGDMedicare PIN
AZWCKGCMedicare PIN
AZWCHBHMedicare PIN