Basic Information
Provider Information | |||||||||
NPI: | 1053781419 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILKERSON | ||||||||
FirstName: | STEVE | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1633 SUGAR HILL ROAD | ||||||||
Address2: | SUITE 1 | ||||||||
City: | MARION | ||||||||
State: | NC | ||||||||
PostalCode: | 28752 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8286593621 | ||||||||
FaxNumber: | 8286595282 | ||||||||
Practice Location | |||||||||
Address1: | 50 SCHENCK PKWY | ||||||||
Address2: | PROVIDER ENROLLMENT | ||||||||
City: | ASHEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 288033499 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8286516590 | ||||||||
FaxNumber: | 8286811577 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/29/2015 | ||||||||
LastUpdateDate: | 09/29/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-05973 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.