Provider Demographics
NPI:1154992337
Name:LAHR, MADISON (PA-C)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:LAHR
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:BLACKWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:435 CLINIC DRIVE
Mailing Address - Street 2:MODULE A
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834
Mailing Address - Country:US
Mailing Address - Phone:910-508-7434
Mailing Address - Fax:
Practice Address - Street 1:435 CLINIC DRIVE
Practice Address - Street 2:MODULE A
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834
Practice Address - Country:US
Practice Address - Phone:910-508-7434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-14067207RE0101X
363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VANAMedicaid