Healthcare Provider Details

I. General information

NPI: 1396073136
Provider Name (Legal Business Name): AMANDA LEIGH PALM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2009
Last Update Date: 02/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 HIGHLAND AVE
MADISON WI
53792-0001
US

IV. Provider business mailing address

7974 UW HEALTH CT
MIDDLETON WI
53562-5531
US

V. Phone/Fax

Practice location:
  • Phone: 608-263-6420
  • Fax: 608-263-0440
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3320-23
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number127852-121
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: