Provider Demographics
NPI:1841182854
Name:MADRID, ROXANNE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ROXANNE
Middle Name:
Last Name:MADRID
Suffix:
Gender:F
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 1:1115 MOHAWK AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-3331
Mailing Address - Country:US
Mailing Address - Phone:773-383-9135
Mailing Address - Fax:
Practice Address - Street 1:1115 MOHAWK AVE
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-3331
Practice Address - Country:US
Practice Address - Phone:773-383-9135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-16
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant