Provider Demographics
NPI:1538750237
Name:SKRETTEBERG, MADDISON RAE
Entity type:Individual
Prefix:
First Name:MADDISON
Middle Name:RAE
Last Name:SKRETTEBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 PINELLAS ST STE 400
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-3356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:455 PINELLAS ST STE 400
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3356
Practice Address - Country:US
Practice Address - Phone:727-445-1911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9117470363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty