Provider Demographics
NPI:1194583856
Name:BALACHIO, MADISON RYAN (PA)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:RYAN
Last Name:BALACHIO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:BALACHIO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:414 N CAMDEN DR STE 1100
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4576
Mailing Address - Country:US
Mailing Address - Phone:805-410-0224
Mailing Address - Fax:
Practice Address - Street 1:414 N CAMDEN DR STE 1100
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4576
Practice Address - Country:US
Practice Address - Phone:310-278-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-07
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
CAPA65323363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical