1538876610 NPI number — MADISON NICHOLE AGUON TAITANO PT, DPT

Table of content: MADISON NICHOLE AGUON TAITANO PT, DPT (NPI 1538876610)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538876610 NPI number — MADISON NICHOLE AGUON TAITANO PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAITANO
Provider First Name:
MADISON
Provider Middle Name:
NICHOLE AGUON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538876610
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16649 W JENAN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SURPRISE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85388-6070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-676-7900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7727 W DEER VALLEY RD STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85382-2120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-208-7575
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/28/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  LPT-32644 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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