Provider Demographics
NPI:1598155129
Name:TANYA WILKE FAMILY MEDICINE
Entity Type:Organization
Organization Name:TANYA WILKE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-825-2849
Mailing Address - Street 1:1427 JEFFERSON AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-3649
Mailing Address - Country:US
Mailing Address - Phone:360-825-2849
Mailing Address - Fax:360-825-5381
Practice Address - Street 1:1427 JEFFERSON AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-3649
Practice Address - Country:US
Practice Address - Phone:360-825-2849
Practice Address - Fax:360-825-5381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-04
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60090609261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0251251OtherSTATE L&I
WA0274400OtherSTATE L&I
WA0251251OtherSTATE L&I
WAG8883295Medicare PIN