Provider Demographics
NPI:1659915171
Name:WILDERMAN, AMANDA MARIE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:WILDERMAN
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 1:1268 COLE PLACE RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62233-2054
Mailing Address - Country:US
Mailing Address - Phone:618-210-7478
Mailing Address - Fax:
Practice Address - Street 1:1100 W DIANN LN
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5339
Practice Address - Country:US
Practice Address - Phone:618-549-8006
Practice Address - Fax:618-549-8434
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-29
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.020318207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine