Provider Demographics
NPI:1043371636
Name:MADRIGAL, MARTIN (PA-C)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:MADRIGAL
Suffix:
Gender:M
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 1:5404 MORENO ST
Mailing Address - Street 2:SUITE N
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-1667
Mailing Address - Country:US
Mailing Address - Phone:909-949-4400
Mailing Address - Fax:909-949-4441
Practice Address - Street 1:5404 MORENO ST
Practice Address - Street 2:SUITE N
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-1667
Practice Address - Country:US
Practice Address - Phone:909-949-4400
Practice Address - Fax:909-949-4441
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17142363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17142OtherSTATE LICENSE NUMBER