Provider Demographics
NPI:1851512636
Name:MADDEN, JEFFREY K (CRNA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:K
Last Name:MADDEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 PALATINE
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-4295
Mailing Address - Country:US
Mailing Address - Phone:478-318-5726
Mailing Address - Fax:
Practice Address - Street 1:2 PALATINE
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-4295
Practice Address - Country:US
Practice Address - Phone:478-318-5722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN159372367500000X
CA95000337367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA344353OtherWELLCARE CMO - MCCG
GAP00319935OtherRAILROAD MCR - MCCG
GA288788035BOtherPEACHSTATE CMO - MCCG
GA288788035BMedicaid
GA43BBBZXMedicare ID - Type UnspecifiedMCCG
GA344353OtherWELLCARE CMO - MCCG
GA288788035BOtherPEACHSTATE CMO - MCCG