Basic Information
| Provider Information | |||||||||
| NPI: | 1164941167 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILKES | ||||||||
| FirstName: | KALEN | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2005 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462062005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174686257 | ||||||||
| FaxNumber: | 3174686268 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 N STATE ST STE 205 | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461401270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173252699 | ||||||||
| FaxNumber: | 3174776977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | IN | N | 193400000X SINGLE SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | 10002307A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.