Provider Demographics
NPI:1164971560
Name:MADRID, AMANDA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:
Last Name:MADRID
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 1:1603 W BRIGADOON PARK DR
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-6598
Mailing Address - Country:US
Mailing Address - Phone:801-647-9278
Mailing Address - Fax:
Practice Address - Street 1:220 MILLPOND
Practice Address - Street 2:
Practice Address - City:STANSBURY PARK
Practice Address - State:UT
Practice Address - Zip Code:84074-9745
Practice Address - Country:US
Practice Address - Phone:435-843-3096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-26
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10097228-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant