Provider Demographics
NPI:1144568767
Name:WILES, AMANDA S (NP-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:WILES
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58107-2168
Mailing Address - Country:US
Mailing Address - Phone:701-234-2119
Mailing Address - Fax:
Practice Address - Street 1:904 5TH AVE NE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-3437
Practice Address - Country:US
Practice Address - Phone:701-253-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013001306363LF0000X
NDR39620363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND84313Medicaid
NDN719662Medicare PIN