Madison Mandula Bazemore, PA
Physician Assistant in Gainesville, GA. Individual provider (NPI-1).
NPI number1306583323
StatusActive
Last updated in NPPESDec 20, 2023
Details
- NPI
- 1306583323
- Entity type
- Individual (NPI-1)
- Name
- Madison Mandula Bazemore
- Credential
- PA
- Sex
- Female
- Sole proprietor
- No
- Enumeration date
- May 20, 2022
- Certification date
- Dec 20, 2023
- Last updated
- Dec 20, 2023
Medicare and OIG
- Medicare enrolled (PECOS)
- Yes · PRACTITIONER - PHYSICIAN ASSISTANT
- Can order and refer
- Part B Yes · DME Yes · Home health Yes · Power mobility Yes · Hospice No
- OIG exclusion list
- This NPI is not listed
CMS and OIG files of November 2026. PECOS lookup · OIG exclusion check
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 363A00000X | Physician Assistant | 11992 | GA | Yes |
| 390200000X | Student in an Organized Health Care Education/Training Program | – | – |
Practice location
1315 Jesse Jewell Pkwy Ne Ste 300Gainesville, GA 30501-3875
Phone 770-848-6190
Mailing address
Po Box 742616Atlanta, GA 30374-2616
Phone 770-219-8420
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This page shows exactly what the provider filed with NPPES. Only the provider (or their surrogate) can change it, by signing in to NPPES. Our page updates within a day of their change. See how to update NPI information.
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All 116 Physician Assistant providers in Gainesville · All 3,664 providers in Gainesville
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