Provider Demographics
NPI:1356989651
Name:DIMATTEI, MADISON GRACE (PA-C)
Entity type:Individual
Prefix:MISS
First Name:MADISON
Middle Name:GRACE
Last Name:DIMATTEI
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 1:303 MAIN ST APT 340
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-1448
Mailing Address - Country:US
Mailing Address - Phone:781-439-8734
Mailing Address - Fax:
Practice Address - Street 1:303 MAIN ST APT 340
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-1448
Practice Address - Country:US
Practice Address - Phone:781-439-8734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-17
Last Update Date:2022-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY026269363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program