Provider Demographics
NPI:1821596073
Name:WILKES, VENICE LUCIA (PA-C)
Entity Type:Individual
Prefix:
First Name:VENICE
Middle Name:LUCIA
Last Name:WILKES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VENICE
Other - Middle Name:LUCIA
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:925 W BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:GLENROCK
Mailing Address - State:WY
Mailing Address - Zip Code:82637-5079
Mailing Address - Country:US
Mailing Address - Phone:307-436-9206
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:5000 BLACKMORE RD
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-3345
Practice Address - Country:US
Practice Address - Phone:307-233-6000
Practice Address - Fax:307-233-6089
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11159450-1206363A00000X
WYPT904363A00000X
FL9110986363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant