MEDICARE: AMY L WILDER HAS, BC-HIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	237700000X	Hearing Instrument Specialist	AS5334	FL

General Provider Information

NPI Number	:	1649732009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY L WILDER HAS, BC-HIS

Provider Business Mailing Address
First Line	:	10929 S US HIGHWAY 1
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34952-6417
Country	:	US
Telephone Number	:	772-337-2526
Fax Number	:	772-337-2589

Provider Business Practice Location Address
First Line	:	10929 S US HIGHWAY 1
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34952-6417
Country	:	US
Telephone Number	:	772-337-2526
Fax Number	:	772-337-2589

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2019
Last Update Date	:	04/04/2019

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