Provider Demographics
NPI:1639106362
Name:WILKERSON, GARY BLAINE (EDD, ATC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:BLAINE
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:EDD, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 BIG ROCK RD
Mailing Address - Street 2:
Mailing Address - City:SIGNAL MOUNTAIN
Mailing Address - State:TN
Mailing Address - Zip Code:37377-2007
Mailing Address - Country:US
Mailing Address - Phone:423-886-2998
Mailing Address - Fax:423-425-5395
Practice Address - Street 1:615 MCCALLIE AVE
Practice Address - Street 2:DEPARTMENT 6606
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2504
Practice Address - Country:US
Practice Address - Phone:423-425-5394
Practice Address - Fax:423-425-5395
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000005022255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer