Provider Demographics
NPI:1104884428
Name:MADISON, COLETTE C (PA)
Entity type:Individual
Prefix:
First Name:COLETTE
Middle Name:C
Last Name:MADISON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:COLETTE
Other - Middle Name:E
Other - Last Name:CHAINTREUIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 CARTER STREET
Mailing Address - Street 2:ATTN KELLY STEELE
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621
Mailing Address - Country:US
Mailing Address - Phone:585-339-4793
Mailing Address - Fax:585-336-4845
Practice Address - Street 1:77 SULLYS TRAIL
Practice Address - Street 2:
Practice Address - City:PITTSFORD
Practice Address - State:NY
Practice Address - Zip Code:14534
Practice Address - Country:US
Practice Address - Phone:585-248-5300
Practice Address - Fax:585-248-3427
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0074431363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY970028206OtherMEDICARE RAILROAD #
NY109289BJOtherPREFERRED CARE #
NYP019007443OtherBLUE CHOICE #
NY9513997OtherIHA #
NYP019007443OtherBLUE CHOICE #
NY970028206OtherMEDICARE RAILROAD #
NY109289BJOtherPREFERRED CARE #