Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | ||
Y | 2251P0200X | Physical Therapist - Pediatrics |
NPI | 1073832184 |
---|---|
Provider Name | Dr. Amanda D Wang |
First Address | St. Peters, MO 63376 |
Second Address | Saint Louis, MO 63139-3525 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/05/2010 |
Last Update Date | 23/09/2016 |