Provider Demographics
NPI:1659487502
Name:WILKES PEDIATRIC CLINIC, PLLC
Entity Type:Organization
Organization Name:WILKES PEDIATRIC CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-903-0096
Mailing Address - Street 1:1925 W PARK DR
Mailing Address - Street 2:
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-3564
Mailing Address - Country:US
Mailing Address - Phone:336-903-0147
Mailing Address - Fax:336-903-1687
Practice Address - Street 1:1925 W PARK DR
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3564
Practice Address - Country:US
Practice Address - Phone:336-903-0147
Practice Address - Fax:336-903-1687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89013NNMedicaid