Provider Demographics
NPI:1972326486
Name:PANAGOULIAS, MADISEN HOPE
Entity type:Individual
Prefix:
First Name:MADISEN
Middle Name:HOPE
Last Name:PANAGOULIAS
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 1:18 FAIR ST APT 3
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2649
Mailing Address - Country:US
Mailing Address - Phone:203-500-5203
Mailing Address - Fax:
Practice Address - Street 1:610 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-1403
Practice Address - Country:US
Practice Address - Phone:212-226-7666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY383769363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics