Basic Information
| Provider Information | |||||||||
| NPI: | 1215687058 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADDOX | ||||||||
| FirstName: | BRYAN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4715 N 350 W | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472508043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7657171790 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1373 E STATE ROAD 62 | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472507328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128010800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2022 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | CS0365835 | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 300062802 | 05 | IN | MEDICAID | 7100813710 | 05 | KY | MEDICAID | 412840155 | 01 | IN | MEDICARE | OTHER |