Provider Demographics
NPI:1467412254
Name:WILKES, MARK S (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:WILKES
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 COTTONWOOD PL
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-9203
Mailing Address - Country:US
Mailing Address - Phone:816-407-7204
Mailing Address - Fax:
Practice Address - Street 1:250 NE MULBERRY ST
Practice Address - Street 2:C/O SJS MEDICAL MANAGEMENT, SUITE 202
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-4533
Practice Address - Country:US
Practice Address - Phone:816-389-4130
Practice Address - Fax:816-389-4140
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO095684367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO913767018Medicaid
MOS558411Medicare PIN
MO913767018Medicaid
MOP00309269Medicare PIN
MOP00291531Medicare PIN
MOJ118411Medicare PIN
MO4528411Medicare PIN