Healthcare Provider Details

I. General information

NPI: 1841163466
Provider Name (Legal Business Name): AMANDA B WILTSIE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2025
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1648 NW 1ST ST
MERIDIAN ID
83642-2212
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-888-9393
  • Fax: 208-888-9525
Mailing address:
  • Phone: 208-955-6500
  • Fax: 208-955-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4781528
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10882553-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: