Provider Demographics
NPI:1134158728
Name:MADRAS, MARY MARGARET (APRN,BC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MARGARET
Last Name:MADRAS
Suffix:
Gender:F
Credentials:APRN,BC
Other - Prefix:MS
Other - First Name:PEGGY
Other - Middle Name:M
Other - Last Name:MADRAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN,BC
Mailing Address - Street 1:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6505 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2001
Practice Address - Country:US
Practice Address - Phone:314-687-2734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO140767363L00000X, 363LF0000X
IL277000522363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily