Provider Demographics
NPI:1386028611
Name:WILKINSON, MARK ALLEN
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:WILKINSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:ALLEN
Other - Last Name:WILKINSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:4621 US HIGHWAY 59
Mailing Address - Street 2:GROVE OK 74344
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-4237
Mailing Address - Country:US
Mailing Address - Phone:918-786-3797
Mailing Address - Fax:918-786-7395
Practice Address - Street 1:4621 US HIGHWAY 59
Practice Address - Street 2:GROVE OK 74344
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-4237
Practice Address - Country:US
Practice Address - Phone:918-786-3797
Practice Address - Fax:918-786-7395
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK344225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant