Provider Demographics
NPI:1982138038
Name:WILKERSON, EDWARD R (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:R
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65215-1000
Mailing Address - Country:US
Mailing Address - Phone:573-441-5175
Mailing Address - Fax:
Practice Address - Street 1:1200 E BROADWAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65215-1000
Practice Address - Country:US
Practice Address - Phone:573-441-5175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-15
Last Update Date:2017-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050383582255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer