Provider Demographics
NPI:1215687058
Name:MADDOX, BRYAN E (NP)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:E
Last Name:MADDOX
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4715 N 350 W
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-8043
Mailing Address - Country:US
Mailing Address - Phone:765-717-1790
Mailing Address - Fax:
Practice Address - Street 1:445 CLIFTY DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-1607
Practice Address - Country:US
Practice Address - Phone:812-273-5372
Practice Address - Fax:812-273-5741
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INCS0365835363LF0000X
IN71012403A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300062802Medicaid
KY7100813710Medicaid
IN300062802Medicaid