Provider Demographics
NPI:1134883903
Name:WILKES, ANDREW DALTON (NP)
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:DALTON
Last Name:WILKES
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 STODDARD DR
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-1331
Mailing Address - Country:US
Mailing Address - Phone:646-369-2548
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL RD STE 2A
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-2253
Practice Address - Country:US
Practice Address - Phone:978-466-2692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2328128363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MARN2328128OtherRN AND NP LICENSE NUMBER