Provider Demographics
NPI:1104201037
Name:WILKES, JAMES R JR (ATC)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:R
Last Name:WILKES
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 N ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-3013
Mailing Address - Country:US
Mailing Address - Phone:215-512-0017
Mailing Address - Fax:
Practice Address - Street 1:1518 N ALLEN ST
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-3013
Practice Address - Country:US
Practice Address - Phone:215-512-0017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART005744390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program