Provider Demographics
NPI:1093968174
Name:WILKERSON, BEESHAE (PA)
Entity Type:Individual
Prefix:
First Name:BEESHAE
Middle Name:
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1682
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-1682
Mailing Address - Country:US
Mailing Address - Phone:616-774-5221
Mailing Address - Fax:616-774-5391
Practice Address - Street 1:1840 WEALTHY ST SE
Practice Address - Street 2:MC 426
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2921
Practice Address - Country:US
Practice Address - Phone:616-774-5221
Practice Address - Fax:616-774-5391
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704225666363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner