Provider Demographics
NPI:1740053222
Name:RAYNOR, MADALYNN MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:MADALYNN
Middle Name:MARIE
Last Name:RAYNOR
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 1:4608 WASHINGTON AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1830
Mailing Address - Country:US
Mailing Address - Phone:336-460-7545
Mailing Address - Fax:
Practice Address - Street 1:610 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1251
Practice Address - Country:US
Practice Address - Phone:304-767-7790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV875363AS0400X
WV2819363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical