Provider Demographics
NPI:1750784617
Name:MADSEN, ROMAN K (PA-S)
Entity type:Individual
Prefix:MR
First Name:ROMAN
Middle Name:K
Last Name:MADSEN
Suffix:
Gender:M
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1185 W 1140 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3011
Mailing Address - Country:US
Mailing Address - Phone:480-278-3374
Mailing Address - Fax:
Practice Address - Street 1:625 N PLAZA DR
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85120-5501
Practice Address - Country:US
Practice Address - Phone:480-278-3374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6220363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant