Basic Information
| Provider Information | |||||||||
| NPI: | 1386996056 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILKS | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LUTHER | ||||||||
| OtherFirstName: | BRENDA | ||||||||
| OtherMiddleName: | KAY | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1529 | ||||||||
| Address2: | |||||||||
| City: | DEER PARK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990061529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 509 EAST D STREET | ||||||||
| Address2: | |||||||||
| City: | DEER PARK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990061529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092765005 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2012 | ||||||||
| LastUpdateDate: | 10/05/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA60314280 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.