Basic Information
| Provider Information | |||||||||
| NPI: | 1982069076 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILK | ||||||||
| FirstName: | KID | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C MS | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WILK | ||||||||
| OtherFirstName: | RYAN | ||||||||
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| OtherCredential: | PA-C MS | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1515 N 400 E STE 104 | ||||||||
| Address2: | |||||||||
| City: | NORTH LOGAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843417595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357556061 | ||||||||
| FaxNumber: | 4359948362 | ||||||||
| Practice Location | |||||||||
| Address1: | 2620 COMMERCIAL WAY STE 140 | ||||||||
| Address2: | |||||||||
| City: | ROCK SPRINGS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829014750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357556061 | ||||||||
| FaxNumber: | 3074482984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2015 | ||||||||
| LastUpdateDate: | 04/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA658 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.