Provider Demographics
NPI:1821066085
Name:WILSON, AMANDA LOUISE (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:LOUISE
Last Name:WILSON
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 1:4016 52ND AVENUE CT NW
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-7632
Mailing Address - Country:US
Mailing Address - Phone:413-221-6113
Mailing Address - Fax:
Practice Address - Street 1:4016 52ND AVENUE CT NW
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-7632
Practice Address - Country:US
Practice Address - Phone:413-221-6113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA205246207R00000X
CT049592207R00000X
MI4301505786207RA0401X
WA60935430207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0126748Medicaid
CT003126944Medicaid
MA0126748Medicaid
MAA32474Medicare PIN
110231040Medicare PIN