Provider Demographics
NPI:1528624772
Name:WERBER, MADISON STAUAB
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:STAUAB
Last Name:WERBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:B
Other - Last Name:STAUB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1128 N IRVING ST APT 613
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22201-7105
Mailing Address - Country:US
Mailing Address - Phone:215-915-6311
Mailing Address - Fax:
Practice Address - Street 1:8101 HINSON FARM RD STE 415
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-3410
Practice Address - Country:US
Practice Address - Phone:703-780-0994
Practice Address - Fax:703-780-0929
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-14
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
VA0110006736363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty