Provider Demographics
NPI:1134165327
Name:WILKES, JOHN (CRNA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WILKES
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 14TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2002 12TH AVE NW
Practice Address - Street 2:SUITE C
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1206
Practice Address - Country:US
Practice Address - Phone:580-226-1251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0036492207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
7542Medicare UPIN