Provider Demographics
NPI:1508235219
Name:WILK, GERALD STANLEY JR
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:STANLEY
Last Name:WILK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5841 NE ORENCO GARDENS DR
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-5128
Mailing Address - Country:US
Mailing Address - Phone:360-910-1840
Mailing Address - Fax:
Practice Address - Street 1:2077 NW TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-8938
Practice Address - Country:US
Practice Address - Phone:360-910-1840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14645225700000X
WAMA 00016097225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist