Provider Demographics
NPI:1093530362
Name:MEDINA, MADISON CAROL (PA-C)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:CAROL
Last Name:MEDINA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15300 WEST AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-4600
Mailing Address - Country:US
Mailing Address - Phone:708-923-4400
Mailing Address - Fax:708-923-4421
Practice Address - Street 1:15300 WEST AVE STE 100
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4600
Practice Address - Country:US
Practice Address - Phone:708-923-4400
Practice Address - Fax:708-923-4421
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-20
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.011066363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty