Provider Demographics
NPI:1700590734
Name:FOUNTAIN, MADISON LEE
Entity Type:Individual
Prefix:MR
First Name:MADISON
Middle Name:LEE
Last Name:FOUNTAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4406 HOPEWELL CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:NC
Mailing Address - Zip Code:27370-7348
Mailing Address - Country:US
Mailing Address - Phone:336-689-0669
Mailing Address - Fax:
Practice Address - Street 1:4406 HOPEWELL CHURCH RD
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:NC
Practice Address - Zip Code:27370-7348
Practice Address - Country:US
Practice Address - Phone:336-689-0669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC304292363LS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LS0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerSchool