Healthcare Provider Details

I. General information

NPI: 1013345644
Provider Name (Legal Business Name): EMMA AMANDA ROSE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAREN AMANDA PIEFER

II. Dates (important events)

Enumeration Date: 10/16/2013
Last Update Date: 01/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 BOWMAN AVE.
MADISON WI
53716
US

IV. Provider business mailing address

521 BOWMAN AVE.
MADISON WI
53716
US

V. Phone/Fax

Practice location:
  • Phone: 608-886-0623
  • Fax: 608-825-3794
Mailing address:
  • Phone: 608-886-0623
  • Fax: 608-825-3794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3237-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: