Provider Demographics
NPI:1790905131
Name:WILK, MARK ANDREW
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANDREW
Last Name:WILK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 W. DAVIS ROAD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-7802
Mailing Address - Country:US
Mailing Address - Phone:602-942-6421
Mailing Address - Fax:602-564-2840
Practice Address - Street 1:2011 W. DAVIS ROAD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-7802
Practice Address - Country:US
Practice Address - Phone:602-942-6421
Practice Address - Fax:602-564-2840
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZROC 165112171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ436908Medicaid
AZ631029Medicaid