Provider Demographics
NPI:1316187057
Name:WILKINSON, KIMBERLY M (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:WILKINSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:M
Other - Last Name:DUSICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8101 CLEARVISTA PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-4696
Practice Address - Country:US
Practice Address - Phone:317-621-6660
Practice Address - Fax:317-621-4473
Is Sole Proprietor?:No
Enumeration Date:2009-02-20
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003302363A00000X
IN10002145A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDB1658OtherRR MEDICARE PTAN (GROUP)
IL920540OtherMEDICARE PTAN (GROUP)
IL920540022OtherMEDICARE PTAN (INDIVIDUAL)
ILP01104053OtherRR MEDICARE PTAN (INDIVIDUAL)
INP01777161OtherRR MEDICARE
INP01777161OtherRR MEDICARE