Basic Information
Provider Information | |||||||||
NPI: | 1396452371 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TREADWAY | ||||||||
FirstName: | MADISON | ||||||||
MiddleName: | TAYLOR | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1928 HEISSER LN | ||||||||
Address2: |   | ||||||||
City: | FUQUAY VARINA | ||||||||
State: | NC | ||||||||
PostalCode: | 275263279 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8283909607 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3333 NC HIGHWAY 242 N | ||||||||
Address2: |   | ||||||||
City: | BENSON | ||||||||
State: | NC | ||||||||
PostalCode: | 275047844 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9198942011 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/31/2022 | ||||||||
LastUpdateDate: | 10/31/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/31/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P2201X | 29616 | NC | Y |   |   |   |   |
No ID Information.