Healthcare Provider Details

I. General information

NPI: 1164330346
Provider Name (Legal Business Name): CARMEN MACKENZIE WILKISON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8080 BLUEBONNET BLVD STE 2000
BATON ROUGE LA
70810-7827
US

IV. Provider business mailing address

8080 BLUEBONNET BLVD STE 1000
BATON ROUGE LA
70810-7827
US

V. Phone/Fax

Practice location:
  • Phone: 225-924-2424
  • Fax: 225-427-8231
Mailing address:
  • Phone: 225-924-2424
  • Fax: 225-408-7980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number354597
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: