Provider Demographics
NPI:1588484141
Name:HUMPHREYS, MADISON AYERS (CAA)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:AYERS
Last Name:HUMPHREYS
Suffix:
Gender:
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 DELPHINE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-3927
Mailing Address - Country:US
Mailing Address - Phone:478-607-1114
Mailing Address - Fax:
Practice Address - Street 1:364 CLIFTON RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-3927
Practice Address - Country:US
Practice Address - Phone:404-778-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-16
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA12910367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA12910OtherGEORGIA MEDICAL BOARD