Basic Information
| Provider Information | |||||||||
| NPI: | 1710607445 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EWING | ||||||||
| FirstName: | MADISON | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1831 HOAGLAND RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT MORRIS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145109424 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 103 MEDICINE WAY RD | ||||||||
| Address2: | |||||||||
| City: | PERIDOT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855425000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284751400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2022 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 049272 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.