Provider Demographics
NPI:1235961954
Name:ROYSTER, MADISON RAE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:RAE
Last Name:ROYSTER
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 1:4199 GATEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-8940
Mailing Address - Country:US
Mailing Address - Phone:812-842-4200
Mailing Address - Fax:
Practice Address - Street 1:4199 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-8940
Practice Address - Country:US
Practice Address - Phone:812-842-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-20
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10004628A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant