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: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

U.S. NAVAL HOSPITAL GUAM FARENHOLT AVE BLDG 50
AGANA HEIGHTS GU
96910
US

IV. Provider business mailing address

PSC 455 BOX 208
FPO AP
96540-0003
US

V. Phone/Fax

Practice location:
  • Phone: 671-344-9340
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number1019881
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0101267521
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101267521
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: