Provider Demographics
NPI:1831787365
Name:MAGAN, MADDISON NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:MADDISON
Middle Name:NICOLE
Last Name:MAGAN
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 1:3404 MCCORMICK WOODS DR
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-4464
Mailing Address - Country:US
Mailing Address - Phone:321-437-9177
Mailing Address - Fax:
Practice Address - Street 1:1561 W FAIRBANKS AVE STE 300
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-4678
Practice Address - Country:US
Practice Address - Phone:407-605-5335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-10
Last Update Date:2021-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113630363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty