Provider Demographics
NPI:1013271238
Name:WILSON, AMANDA MARY (DO)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARY
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 30TH AVE W
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-3426
Mailing Address - Country:US
Mailing Address - Phone:320-763-5123
Mailing Address - Fax:
Practice Address - Street 1:610 30TH AVE W
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3426
Practice Address - Country:US
Practice Address - Phone:320-763-5123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-03
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN67864207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025281500Medicaid
NE099751007Medicare PIN