Healthcare Provider Details

I. General information

NPI: 1548238066
Provider Name (Legal Business Name): AMANDA S WILSON ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5544 WILLOW SPRINGS RD
LA GRANGE HIGHLANDS IL
60525-3474
US

IV. Provider business mailing address

5544 WILLOW SPRINGS RD
LA GRANGE HIGHLANDS IL
60525-3474
US

V. Phone/Fax

Practice location:
  • Phone: 708-205-1961
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: