Provider Demographics
NPI:1215508114
Name:MALMQUIST, MADISON R (PA-C)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:R
Last Name:MALMQUIST
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:GARRETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2122 MANCHESTER EXPY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-6878
Mailing Address - Country:US
Mailing Address - Phone:706-596-4000
Mailing Address - Fax:
Practice Address - Street 1:2122 MANCHESTER EXPY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6878
Practice Address - Country:US
Practice Address - Phone:706-596-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-02
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA14751363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant