Provider Demographics
NPI:1912574823
Name:FUGATE, MADISON LANE (PA)
Entity Type:Individual
Prefix:MRS
First Name:MADISON
Middle Name:LANE
Last Name:FUGATE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2861 NE INDEPENDENCE AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-2379
Mailing Address - Country:US
Mailing Address - Phone:816-525-2840
Mailing Address - Fax:
Practice Address - Street 1:2861 NE INDEPENDENCE AVE STE 201
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64064-2379
Practice Address - Country:US
Practice Address - Phone:816-525-2840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2021046816363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program