Basic Information
| Provider Information | |||||||||
| NPI: | 1144568767 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILES | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2168 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581072168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012342119 | ||||||||
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| Practice Location | |||||||||
| Address1: | 904 5TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584013437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012534000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2013 | ||||||||
| LastUpdateDate: | 08/12/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2013001306 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LX0106X | R39620 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Occupational Health |
ID Information
| ID | Type | State | Issuer | Description | 84313 | 05 | ND | MEDICAID |