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 1:22255 GREENFIELD RD STE 590
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3734
Practice Address - Country:US
Practice Address - Phone:248-849-4990
Practice Address - Fax:248-849-4991
Is Sole Proprietor?:No
Enumeration Date:2005-10-01
Last Update Date:2024-09-11
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