Provider Demographics
NPI:1508616681
Name:WILKERSON, TRAE
Entity Type:Individual
Prefix:
First Name:TRAE
Middle Name:
Last Name:WILKERSON
Suffix:
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 1:1603 CAPITOL AVE STE 415
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4562
Mailing Address - Country:US
Mailing Address - Phone:410-999-5758
Mailing Address - Fax:
Practice Address - Street 1:1603 CAPITOL AVE STE 415
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4562
Practice Address - Country:US
Practice Address - Phone:410-999-5758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Y00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Health Information