Provider Demographics
NPI:1114472396
Name:STOUT, EMILY ROSE (PA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ROSE
Last Name:STOUT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 SANDRA DR
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-6137
Mailing Address - Country:US
Mailing Address - Phone:203-464-1909
Mailing Address - Fax:
Practice Address - Street 1:339 HEMINGWAY AVE
Practice Address - Street 2:
Practice Address - City:EAST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06512-5341
Practice Address - Country:US
Practice Address - Phone:203-468-9775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CT003640363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant