Provider Demographics
NPI:1699575704
Name:SHEVCHENKO, MADISON ROSE DENTON (PA)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:ROSE DENTON
Last Name:SHEVCHENKO
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:ROSE
Other - Last Name:DENTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3055 ALVARADO ST STE 106
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-5711
Mailing Address - Country:US
Mailing Address - Phone:510-969-4253
Mailing Address - Fax:510-550-3686
Practice Address - Street 1:3055 ALVARADO ST STE 106
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-5711
Practice Address - Country:US
Practice Address - Phone:510-969-4253
Practice Address - Fax:510-550-3686
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA66060363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty