Provider Demographics
NPI:1114641578
Name:WILKES, PETER BRIAN (DC)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:BRIAN
Last Name:WILKES
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 E BURNSIDE ST STE 213
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1768
Mailing Address - Country:US
Mailing Address - Phone:503-234-4288
Mailing Address - Fax:503-234-8613
Practice Address - Street 1:2705 E BURNSIDE ST STE 213
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1768
Practice Address - Country:US
Practice Address - Phone:503-234-4288
Practice Address - Fax:503-234-8613
Is Sole Proprietor?:No
Enumeration Date:2022-09-29
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6243111NN0400X, 111NX0100X, 111NX0800X, 111NR0400X, 111NX0100X, 111NX0800X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NN0400XChiropractic ProvidersChiropractorNeurology
No111NX0100XChiropractic ProvidersChiropractorOccupational Health
No111NX0800XChiropractic ProvidersChiropractorOrthopedic