Basic Information
| Provider Information | |||||||||
| NPI: | 1023062569 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILKS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 103 W BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378014703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652731752 | ||||||||
| FaxNumber: | 8652731755 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 ASSOCIATES BLVD | ||||||||
| Address2: | |||||||||
| City: | ALCOA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377011943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652386400 | ||||||||
| FaxNumber: | 8652386404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 06/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1069 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.