Provider Demographics
NPI:1114369089
Name:MADDEN, KATIE L (PA-C)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:L
Last Name:MADDEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:INGERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:95 E CHAUTAUQUA ST
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14757-1017
Mailing Address - Country:US
Mailing Address - Phone:716-753-7107
Mailing Address - Fax:716-753-5367
Practice Address - Street 1:320 PRATHER AVE
Practice Address - Street 2:SUITE 100, 200, & 400
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6820
Practice Address - Country:US
Practice Address - Phone:716-338-0022
Practice Address - Fax:716-338-1567
Is Sole Proprietor?:No
Enumeration Date:2013-07-22
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016751363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant