Provider Demographics
NPI:1790394641
Name:WILKE, TYLER (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:
Last Name:WILKE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E SPRING ST APT 229
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-2989
Mailing Address - Country:US
Mailing Address - Phone:859-486-4504
Mailing Address - Fax:
Practice Address - Street 1:3145 HAMILTON MASON RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45011-8557
Practice Address - Country:US
Practice Address - Phone:513-853-9250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003443A208VP0014X, 363A00000X
OH50.006846RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine