Healthcare Provider Details

I. General information

NPI: 1447404496
Provider Name (Legal Business Name): AMY L WILSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2008
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 EAST ADAMS STREET
SYRACUSE NY
13210
US

IV. Provider business mailing address

301 PROSPECT AVE
SYRACUSE NY
13203-1807
US

V. Phone/Fax

Practice location:
  • Phone: 315-448-2713
  • Fax: 315-744-1321
Mailing address:
  • Phone: 315-448-5111
  • Fax: 315-703-5079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number335606
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number335606
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number335606
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: