Provider Demographics
NPI:1205670742
Name:STANDLEY, MADELYNE (PA-C)
Entity type:Individual
Prefix:
First Name:MADELYNE
Middle Name:
Last Name:STANDLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:MI
Mailing Address - Zip Code:49012-9316
Mailing Address - Country:US
Mailing Address - Phone:269-425-0402
Mailing Address - Fax:
Practice Address - Street 1:200 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:MI
Practice Address - Zip Code:49012-9316
Practice Address - Country:US
Practice Address - Phone:269-425-0402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant