Provider Demographics
NPI:1518623321
Name:EDISON, AMANDA CATHERINE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:CATHERINE
Last Name:EDISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 STOCKADE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06073-2118
Mailing Address - Country:US
Mailing Address - Phone:860-331-0060
Mailing Address - Fax:
Practice Address - Street 1:157 STOCKADE RD
Practice Address - Street 2:
Practice Address - City:SOUTH GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06073-2118
Practice Address - Country:US
Practice Address - Phone:860-331-0060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT5583363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program