Provider Demographics
NPI:1033106331
Name:CONNOLLY, AMY G (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:G
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7348 RAFFORD LN
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3190
Mailing Address - Country:US
Mailing Address - Phone:248-592-0733
Mailing Address - Fax:
Practice Address - Street 1:20400 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-3242
Practice Address - Country:US
Practice Address - Phone:313-271-0500
Practice Address - Fax:313-271-9313
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002695363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00191570OtherRAILROAD MEDICARE
P39241Medicare UPIN
N85980001Medicare ID - Type Unspecified