Healthcare Provider Details

I. General information

NPI: 1720546351
Provider Name (Legal Business Name): JORDAN REID WILKES DNP, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2019
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 NEW BERN AVE
RALEIGH NC
27610-1231
US

IV. Provider business mailing address

3100 SPRING FOREST RD STE 130
RALEIGH NC
27616-2880
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-8000
  • Fax:
Mailing address:
  • Phone: 919-350-5645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number226934
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number6472
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: