Healthcare Provider Details

I. General information

NPI: 1508350091
Provider Name (Legal Business Name): AMANDA NICOLE WALTOS HIEGER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10777 SUNSET OFFICE DR STE 200
SAINT LOUIS MO
63127-1019
US

IV. Provider business mailing address

9874 VICKSBURG SIEGE CT
SAINT LOUIS MO
63123-1809
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-4802
  • Fax:
Mailing address:
  • Phone: 440-666-0410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2018020849
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: