Provider Demographics
NPI:1205897279
Name:MADSON, LAURA ANN (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:MADSON
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:920-453-6207
Mailing Address - Fax:
Practice Address - Street 1:N6928 JOHNSONVILLE WAY
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN FALLS
Practice Address - State:WI
Practice Address - Zip Code:53085-1279
Practice Address - Country:US
Practice Address - Phone:920-453-6207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2117363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN839633700Medicaid
WI41938600Medicaid