Provider Demographics
NPI:1164025672
Name:WILSON, AMANDA ROSE (NP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-474-1224
Mailing Address - Fax:
Practice Address - Street 1:89 GENESEE ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14611-3201
Practice Address - Country:US
Practice Address - Phone:585-723-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY701776163WC0200X
NY431739363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology