Provider Demographics
NPI:1770329070
Name:GREEN, MADISON (PA-C)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:GREEN
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 1:7700 W ASPERA BLVD APT 2002
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-7924
Mailing Address - Country:US
Mailing Address - Phone:435-669-0313
Mailing Address - Fax:
Practice Address - Street 1:6780 W THUNDERBIRD RD # A101
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5049
Practice Address - Country:US
Practice Address - Phone:602-843-1991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-05
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10495363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant