Provider Demographics
NPI:1578305009
Name:SHORT, MADISON LEIGH (PA-C)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:LEIGH
Last Name:SHORT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1867 WATER OAK WAY
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-7421
Mailing Address - Country:US
Mailing Address - Phone:463-201-7955
Mailing Address - Fax:
Practice Address - Street 1:509 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-1317
Practice Address - Country:US
Practice Address - Phone:317-678-6402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10004406A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant