Provider Demographics
NPI:1467108027
Name:WILMOT, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WILMOT
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:PO BOX 2249
Mailing Address - Street 2:
Mailing Address - City:GANSEVOORT
Mailing Address - State:NY
Mailing Address - Zip Code:12831-5249
Mailing Address - Country:US
Mailing Address - Phone:518-316-9952
Mailing Address - Fax:
Practice Address - Street 1:170 COUNTY ROUTE 70
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:NY
Practice Address - Zip Code:12170-2103
Practice Address - Country:US
Practice Address - Phone:518-316-9952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCD47979QMedicaid