Provider Demographics
NPI:1992181036
Name:BROWN, MADISON ELIZABETH MOORE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:ELIZABETH MOORE
Last Name:BROWN
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 1:440 COLONIAL TRL W STE 205
Mailing Address - Street 2:
Mailing Address - City:DENDRON
Mailing Address - State:VA
Mailing Address - Zip Code:23839-2205
Mailing Address - Country:US
Mailing Address - Phone:747-294-3981
Mailing Address - Fax:
Practice Address - Street 1:440 COLONIAL TRL W
Practice Address - Street 2:
Practice Address - City:DENDRON
Practice Address - State:VA
Practice Address - Zip Code:23839-2205
Practice Address - Country:US
Practice Address - Phone:757-294-3981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-30
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005009363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical