Provider Demographics
NPI:1306467642
Name:REBHOLZ, MADISON TAYLOR (PA-C)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:TAYLOR
Last Name:REBHOLZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:TAYLOR
Other - Last Name:WALROD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8450 NORTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-1381
Mailing Address - Country:US
Mailing Address - Phone:317-802-2000
Mailing Address - Fax:317-802-2170
Practice Address - Street 1:8450 NORTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-1381
Practice Address - Country:US
Practice Address - Phone:317-802-2000
Practice Address - Fax:317-802-2170
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INCV2002459363A00000X
IN10003014A363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical