Provider Demographics
NPI:1730709775
Name:MARKSTROM, MADELINE ELIZABETH (PA)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:ELIZABETH
Last Name:MARKSTROM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:ELIZABETH
Other - Last Name:LUMMIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:660 OCEAN AVE APT 110
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-1285
Mailing Address - Country:US
Mailing Address - Phone:916-704-0167
Mailing Address - Fax:
Practice Address - Street 1:6620 COYLE AVE STE 303
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-6337
Practice Address - Country:US
Practice Address - Phone:916-965-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant