Provider Demographics
NPI:1770206385
Name:MARTIN, MADISON (PA)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 CHESTNUT RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR TREE
Mailing Address - State:TN
Mailing Address - Zip Code:38380-5448
Mailing Address - Country:US
Mailing Address - Phone:731-780-7418
Mailing Address - Fax:
Practice Address - Street 1:2290 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38012-1607
Practice Address - Country:US
Practice Address - Phone:731-772-5183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical