Provider Demographics
NPI:1235339359
Name:WILKE, TANYA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:TANYA
Middle Name:MARIE
Last Name:WILKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1427 JEFFERSON AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-3649
Mailing Address - Country:US
Mailing Address - Phone:360-825-2849
Mailing Address - Fax:360-825-5381
Practice Address - Street 1:1427 JEFFERSON AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-3649
Practice Address - Country:US
Practice Address - Phone:360-825-2849
Practice Address - Fax:360-825-5381
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2015-01-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAML20008540207Q00000X
WAMD60090609207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0274400OtherSTATE L&I
WA0251251OtherSTATE L&I
WAG8883295Medicare PIN
WA0274400OtherSTATE L&I