Provider Demographics
NPI:1144858796
Name:SCHMOELLER, MADISON JEAN (PA-C)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:JEAN
Last Name:SCHMOELLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:JEAN
Other - Last Name:WEIDEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5169 S COTTONWOOD ST STE 610
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6771
Mailing Address - Country:US
Mailing Address - Phone:801-507-3731
Mailing Address - Fax:801-507-3738
Practice Address - Street 1:5169 S COTTONWOOD ST STE 610
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6771
Practice Address - Country:US
Practice Address - Phone:801-507-3731
Practice Address - Fax:801-507-3738
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-10588363A00000X
UT12862515-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant