Healthcare Provider Details

I. General information

NPI: 1962991836
Provider Name (Legal Business Name): AMANDA LOUISE WILDER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2018
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL MEDICAL CENTER SAN DIEGO 38400 BOB WILSON DR
SAN DIEGO CA
92134-5000
US

IV. Provider business mailing address

MCAGCC BOX 7888260
29 PALMS CA
92278
US

V. Phone/Fax

Practice location:
  • Phone: 813-679-0028
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0101267521
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: