Provider Demographics
NPI:1700497443
Name:MADDOX, MICHAEL CAMERON (RN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CAMERON
Last Name:MADDOX
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:742 BONNIE LN
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-5460
Mailing Address - Country:US
Mailing Address - Phone:925-565-3169
Mailing Address - Fax:
Practice Address - Street 1:742 BONNIE LN
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-5460
Practice Address - Country:US
Practice Address - Phone:925-565-3169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-16
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95198315163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse