Provider Demographics
NPI:1932642956
Name:WILKINSON, IAN (LAC)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:WILKINSON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64718 STARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-8426
Mailing Address - Country:US
Mailing Address - Phone:541-706-1888
Mailing Address - Fax:
Practice Address - Street 1:4829 NE MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3491
Practice Address - Country:US
Practice Address - Phone:541-706-1888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC179984171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist