Provider Demographics
NPI:1477093706
Name:WILKS, SHAUNTE (PA-C)
Entity Type:Individual
Prefix:
First Name:SHAUNTE
Middle Name:
Last Name:WILKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHAUNTE
Other - Middle Name:
Other - Last Name:YATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:151 SOUTHHALL LN
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7176
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:80 W GRANT ST STE 117
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-3909
Practice Address - Country:US
Practice Address - Phone:407-770-0139
Practice Address - Fax:407-770-0182
Is Sole Proprietor?:No
Enumeration Date:2017-03-06
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109978363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant