Provider Demographics
NPI:1861702094
Name:MADISON, ADEEN RODD (PA)
Entity type:Individual
Prefix:
First Name:ADEEN
Middle Name:RODD
Last Name:MADISON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 WOODROW RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-1726
Mailing Address - Country:US
Mailing Address - Phone:718-227-1846
Mailing Address - Fax:
Practice Address - Street 1:1318 WOODROW RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-1726
Practice Address - Country:US
Practice Address - Phone:718-227-1846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001015-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant