Provider Demographics
NPI:1376748095
Name:WILKERSON, CARLIE JEANETTE (PA)
Entity Type:Individual
Prefix:
First Name:CARLIE
Middle Name:JEANETTE
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 SONOMA AVE STE 20
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4813
Mailing Address - Country:US
Mailing Address - Phone:707-525-0696
Mailing Address - Fax:707-525-8404
Practice Address - Street 1:990 SONOMA AVE STE 20
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4813
Practice Address - Country:US
Practice Address - Phone:707-525-0696
Practice Address - Fax:707-525-8404
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19226363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical