Provider Demographics
NPI:1447760376
Name:WILKERSON, PHILLIP CURTIS (ATC)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:CURTIS
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:413 LAKE HAVASU DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-3976
Mailing Address - Country:US
Mailing Address - Phone:757-381-3280
Mailing Address - Fax:
Practice Address - Street 1:4251 POWHATAN AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23508-2225
Practice Address - Country:US
Practice Address - Phone:757-683-4255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260028362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0126002836OtherSTATE LICENSURE
IL096.002700OtherSTATE LICENSURE
AR408OtherSTATE LICENSURE
OH003741OtherSTATE LICENSURE
120402189OtherBOC CERTIFICATION