Provider Demographics
NPI:1710593520
Name:WILKERSON, BOBBY DON (PTA)
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:DON
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2760 N GRANDVIEW AVE STE A
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-6953
Mailing Address - Country:US
Mailing Address - Phone:432-552-7034
Mailing Address - Fax:432-552-7165
Practice Address - Street 1:2760 N GRANDVIEW AVE STE A
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-6953
Practice Address - Country:US
Practice Address - Phone:432-552-7034
Practice Address - Fax:432-552-7165
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-17
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2078260225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant