Provider Demographics
NPI:1174041636
Name:WILSON, AMANDA CATHERINE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:CATHERINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 N WALDRON ST
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67502-1197
Mailing Address - Country:US
Mailing Address - Phone:620-669-2500
Mailing Address - Fax:
Practice Address - Street 1:2101 N WALDRON ST
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502-1197
Practice Address - Country:US
Practice Address - Phone:620-669-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-02015363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant