1447760376 NPI number — PHILLIP CURTIS WILKERSON ATC

Table of content: (NPI 1386864163)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447760376 NPI number — PHILLIP CURTIS WILKERSON ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILKERSON
Provider First Name:
PHILLIP
Provider Middle Name:
CURTIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
N/A
Provider Other First Name:
N/A
Provider Other Middle Name:
N/A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1447760376
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
413 LAKE HAVASU DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23454-3976
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-381-3280
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4251 POWHATAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23508-2225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-683-4255
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/05/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  0126002836 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0126002836 . This is a "STATE LICENSURE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 096.002700 . This is a "STATE LICENSURE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 408 . This is a "STATE LICENSURE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 003741 . This is a "STATE LICENSURE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 120402189 . This is a "BOC CERTIFICATION" identifier . This identifiers is of the category "OTHER".




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