Provider Demographics
NPI:1912369802
Name:WILKIE, DEVON ROLAND AUGUSTUS
Entity Type:Individual
Prefix:
First Name:DEVON
Middle Name:ROLAND AUGUSTUS
Last Name:WILKIE
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 1:241 RIVEREDGE DR
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:DE
Mailing Address - Zip Code:19720-8705
Mailing Address - Country:US
Mailing Address - Phone:302-757-4582
Mailing Address - Fax:
Practice Address - Street 1:1755 WITTINGTON PL
Practice Address - Street 2:#175
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-1927
Practice Address - Country:US
Practice Address - Phone:302-757-4582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0003425225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist