Provider Demographics
NPI:1023122116
Name:WILKS, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:WILKS
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 1:800 BRADBURY DR SE STE 116
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4310
Mailing Address - Country:US
Mailing Address - Phone:505-272-1476
Mailing Address - Fax:505-272-8060
Practice Address - Street 1:UNM DEPARTMENT OF EMERGENCY MEDICINE MSC11-6025
Practice Address - Street 2:1 UNIVERSITY OF NEW MEXICO
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-5062
Practice Address - Fax:505-925-7290
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25397207P00000X
NY242863207P00000X
NMMD2012-0390207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00278965OtherRAILROAD MEDICARE
AZ107241Medicare ID - Type Unspecified
AZ388191Medicaid
AZ86080015085259B089OtherCHAMPUS
AZH07426Medicare UPIN
NYJ400066844Medicare PIN
NY02845307Medicaid