Provider Demographics
NPI:1053563346
Name:WILSON, AMANDA LEIGH (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEIGH
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 W OKLAHOMA AVE
Mailing Address - Street 2:ACL LABORATORIES
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4330
Mailing Address - Country:US
Mailing Address - Phone:414-649-5831
Mailing Address - Fax:414-649-7850
Practice Address - Street 1:2900 W OKLAHOMA AVE
Practice Address - Street 2:ACL LABORATORIES
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4330
Practice Address - Country:US
Practice Address - Phone:414-649-5831
Practice Address - Fax:414-649-7850
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24161207ZP0102X
IL036.119951207ZP0102X
WI55862-20207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology