Healthcare Provider Details

I. General information

NPI: 1134883903
Provider Name (Legal Business Name): ANDREW DALTON WILKES NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL RD STE 2A
LEOMINSTER MA
01453-2253
US

IV. Provider business mailing address

12 STODDARD DR
WORCESTER MA
01604-1331
US

V. Phone/Fax

Practice location:
  • Phone: 978-466-2692
  • Fax:
Mailing address:
  • Phone: 646-369-2548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2328128
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: