Provider Demographics
NPI:1043852411
Name:GAGERN, MADISON WYLIE HAWKES
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:WYLIE HAWKES
Last Name:GAGERN
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 1:253 POE CT
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-2136
Mailing Address - Country:US
Mailing Address - Phone:301-873-2902
Mailing Address - Fax:
Practice Address - Street 1:3407 WILKENS AVE STE 250
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5222
Practice Address - Country:US
Practice Address - Phone:410-646-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-17
Last Update Date:2024-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant