Provider Demographics
NPI:1104898436
Name:MADKOUR, AMANDA (PA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MADKOUR
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 1:51-53 KENOSIA AVE
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-2304
Mailing Address - Country:US
Mailing Address - Phone:203-748-0330
Mailing Address - Fax:203-797-0255
Practice Address - Street 1:51-53 KENOSIA AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-2304
Practice Address - Country:US
Practice Address - Phone:203-748-0330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001399207R00000X
CT52744208800000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT290001399CT01OtherANTHEM BC/BS
CT139900OtherCONNECTCARE
CTP3188856OtherOXFORD
CTP3188856OtherOXFORD
CTQ04316Medicare UPIN