Healthcare Provider Details

I. General information

NPI: 1477067239
Provider Name (Legal Business Name): MADISON ELIZABETH AMOS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2017
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 MAIN AVE STE 102
NORWALK CT
06851-1080
US

IV. Provider business mailing address

761 MAIN AVE STE 102
NORWALK CT
06851-1080
US

V. Phone/Fax

Practice location:
  • Phone: 203-810-4151
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0005175
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5030
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number62769
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: