Provider Demographics
NPI:1285674044
Name:WIKTOR, RALPH (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RALPH
Middle Name:
Last Name:WIKTOR
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2861 LAKE CHARNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-2120
Mailing Address - Country:US
Mailing Address - Phone:313-434-2439
Mailing Address - Fax:248-250-9566
Practice Address - Street 1:10683 S SAGINAW ST STE B
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8127
Practice Address - Country:US
Practice Address - Phone:810-771-4074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003281363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIS98286Medicare UPIN
MI0N68490014Medicare ID - Type Unspecified