Provider Demographics
NPI:1710363023
Name:WIGGINS, AMANDA (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WIGGINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-916-1523
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-1523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU5263207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN