Provider Demographics
NPI:1679832489
Name:WILKE, TRACI (PA)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:
Last Name:WILKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3726 S TIMBERLINE RD
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4331
Mailing Address - Country:US
Mailing Address - Phone:970-221-5795
Mailing Address - Fax:970-221-1371
Practice Address - Street 1:3726 S TIMBERLINE RD
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4331
Practice Address - Country:US
Practice Address - Phone:970-221-5795
Practice Address - Fax:970-221-1371
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16810363A00000X
CO0003504363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant