Healthcare Provider Details

I. General information

NPI: 1245447333
Provider Name (Legal Business Name): AMY T WILBORN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CHILDRENS LN
NORFOLK VA
23507-1971
US

IV. Provider business mailing address

625 E MOWBRAY CT
NORFOLK VA
23507-1858
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-7320
  • Fax:
Mailing address:
  • Phone: 757-681-3808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number0101240398
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: