Provider Demographics
NPI:1003073545
Name:WILSON, AMANDA MOBERG (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:MOBERG
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 5TH AVE
Mailing Address - Street 2:# 407
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6928
Mailing Address - Country:US
Mailing Address - Phone:917-715-2886
Mailing Address - Fax:
Practice Address - Street 1:21 W 86TH ST
Practice Address - Street 2:SUITE 209
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-3671
Practice Address - Country:US
Practice Address - Phone:917-715-2886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYDO NOT HAVE ONE-PGY12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry