Provider Demographics
NPI:1841731817
Name:WILKE, DELETRA MICHELLE (PA-C)
Entity type:Individual
Prefix:
First Name:DELETRA
Middle Name:MICHELLE
Last Name:WILKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 808
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763-0808
Mailing Address - Country:US
Mailing Address - Phone:865-224-7172
Mailing Address - Fax:865-224-7171
Practice Address - Street 1:3959 HIGHWAY 411
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37354-4417
Practice Address - Country:US
Practice Address - Phone:423-442-2121
Practice Address - Fax:423-545-9556
Is Sole Proprietor?:No
Enumeration Date:2017-03-10
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3239363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant