Provider Demographics
NPI:1982069076
Name:WILK, KID (PA-C MS)
Entity Type:Individual
Prefix:
First Name:KID
Middle Name:
Last Name:WILK
Suffix:
Gender:M
Credentials:PA-C MS
Other - Prefix:
Other - First Name:RYAN
Other - Middle Name:
Other - Last Name:WILK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C MS
Mailing Address - Street 1:1515 N 400 E STE 104
Mailing Address - Street 2:
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-7595
Mailing Address - Country:US
Mailing Address - Phone:435-755-6061
Mailing Address - Fax:435-994-8362
Practice Address - Street 1:2620 COMMERCIAL WAY STE 140
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4750
Practice Address - Country:US
Practice Address - Phone:435-755-6061
Practice Address - Fax:307-448-2984
Is Sole Proprietor?:No
Enumeration Date:2015-12-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPA658363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant