Provider Demographics
NPI:1124470745
Name:MCGUIRE, AMANDA (DPM)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MCGUIRE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:WHEATLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:6625 LYNDALE AVE S STE 300
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2491
Mailing Address - Country:US
Mailing Address - Phone:612-788-8778
Mailing Address - Fax:612-869-3473
Practice Address - Street 1:6625 LYNDALE AVE S STE 105
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2673
Practice Address - Country:US
Practice Address - Phone:612-788-8778
Practice Address - Fax:612-869-3473
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL135000923213ES0103X
MN1084213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1084OtherPROFESSIONAL LICENSE
MN1124470745Medicaid
IL135000923OtherPROFESSIONAL LICENSE
IL016005791Medicaid