Provider Demographics
NPI:1477120426
Name:MASTERS, MADISON MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:MARIE
Last Name:MASTERS
Suffix:
Gender:
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 1:4235 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4299
Mailing Address - Country:US
Mailing Address - Phone:419-473-3561
Mailing Address - Fax:419-479-5593
Practice Address - Street 1:106 S LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-1404
Practice Address - Country:US
Practice Address - Phone:947-348-1176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0464392Medicaid