Provider Demographics
NPI:1598075616
Name:WILKENS, BRUCE FREDERICK (PA)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:FREDERICK
Last Name:WILKENS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28455 HAGGERTY RD
Mailing Address - Street 2:STE 200
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2982
Mailing Address - Country:US
Mailing Address - Phone:248-893-3200
Mailing Address - Fax:248-893-2951
Practice Address - Street 1:28455 HAGGERTY RD
Practice Address - Street 2:STE 200
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2982
Practice Address - Country:US
Practice Address - Phone:248-893-3200
Practice Address - Fax:248-893-2951
Is Sole Proprietor?:No
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005889363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601005889OtherSTATE LICENSE