Provider Demographics
NPI:1467826776
Name:WILSON, AMANDA N (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:N
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:N
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3884 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14227-1111
Mailing Address - Country:US
Mailing Address - Phone:716-681-9000
Mailing Address - Fax:716-256-1079
Practice Address - Street 1:3884 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14227-1111
Practice Address - Country:US
Practice Address - Phone:716-681-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-24
Last Update Date:2021-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018561363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY8391586OtherCIGNA
NY8204874OtherMVP
NY8391586OtherCIGNA