Provider Demographics
NPI:1750545737
Name:HENRY, MADONNA MOORE (PA-C)
Entity type:Individual
Prefix:
First Name:MADONNA
Middle Name:MOORE
Last Name:HENRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:210 EAST DERENNE AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4801
Mailing Address - Country:US
Mailing Address - Phone:912-644-5300
Mailing Address - Fax:912-644-3369
Practice Address - Street 1:16915 HIGHWAY 67
Practice Address - Street 2:SUITE A
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5819
Practice Address - Country:US
Practice Address - Phone:912-644-5300
Practice Address - Fax:912-644-5260
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2017-05-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA005351363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant