Provider Demographics
NPI:1013345644
Name:ROSE, EMMA AMANDA (PA-C)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:AMANDA
Last Name:ROSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MAREN
Other - Middle Name:AMANDA
Other - Last Name:PIEFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:521 BOWMAN AVE.
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53716
Mailing Address - Country:US
Mailing Address - Phone:608-886-0623
Mailing Address - Fax:608-825-3794
Practice Address - Street 1:521 BOWMAN AVE.
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716
Practice Address - Country:US
Practice Address - Phone:608-886-0623
Practice Address - Fax:608-825-3794
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3237-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400184200Medicare PIN