MEDICARE: BRENDA KAY WILKS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA60314280	WA

General Provider Information

NPI Number	:	1386996056
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA KAY WILKS PA-C

Provider Business Mailing Address
First Line	:	PO BOX 1529
Second Line	:
City	:	DEER PARK
State	:	WA
Zip	:	99006-1529
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	509 EAST D STREET
Second Line	:
City	:	DEER PARK
State	:	WA
Zip	:	99006-1529
Country	:	US
Telephone Number	:	509-276-5005
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2012
Last Update Date	:	10/05/2012

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