Basic Information
| Provider Information | |||||||||
| NPI: | 1023031655 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHOW | ||||||||
| FirstName: | MADELINE | ||||||||
| MiddleName: | TAM | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TAM | ||||||||
| OtherFirstName: | MADELINE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | N.P. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1510 4TH ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947101717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105258980 | ||||||||
| FaxNumber: | 5105258982 | ||||||||
| Practice Location | |||||||||
| Address1: | 1510 4TH ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947101717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105258980 | ||||||||
| FaxNumber: | 5105258982 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 08/05/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 10811 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | MT0629874 | 01 | CA | DEA | OTHER | NP0108110 | 05 | CA | MEDICAID |