Basic Information
| Provider Information | |||||||||
| NPI: | 1790394641 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILKE | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 E SPRING ST APT 229 | ||||||||
| Address2: | |||||||||
| City: | NEW ALBANY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471502989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594864504 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3145 HAMILTON MASON RD | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD TOWNSHIP | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450118557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138539250 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2020 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | 10003443A | IN | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 363A00000X | 10003443A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 50.006846RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.