Provider Demographics
NPI:1225235666
Name:WILKE, LANCE WAYNE (ATC, LAT, CSCS, PES)
Entity Type:Individual
Prefix:MR
First Name:LANCE
Middle Name:WAYNE
Last Name:WILKE
Suffix:
Gender:M
Credentials:ATC, LAT, CSCS, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:INGRAM
Mailing Address - State:TX
Mailing Address - Zip Code:78025-3126
Mailing Address - Country:US
Mailing Address - Phone:830-367-2803
Mailing Address - Fax:
Practice Address - Street 1:101 HILLSIDE DR
Practice Address - Street 2:
Practice Address - City:INGRAM
Practice Address - State:TX
Practice Address - Zip Code:78025-3126
Practice Address - Country:US
Practice Address - Phone:830-367-2803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT15832255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer