Provider Demographics
NPI:1699494716
Name:MAINES, MADISON SUZANNA (PA-C)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:SUZANNA
Last Name:MAINES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 ROUTE 70 STE 100
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-9501
Mailing Address - Country:US
Mailing Address - Phone:609-267-9400
Mailing Address - Fax:
Practice Address - Street 1:131 ROUTE 70 STE 100
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-9501
Practice Address - Country:US
Practice Address - Phone:609-267-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00726400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant