Healthcare Provider Details

I. General information

NPI: 1114641578
Provider Name (Legal Business Name): PETER BRIAN WILKES DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 E BURNSIDE ST STE 213
PORTLAND OR
97214-1768
US

IV. Provider business mailing address

2705 E BURNSIDE ST STE 213
PORTLAND OR
97214-1768
US

V. Phone/Fax

Practice location:
  • Phone: 503-234-4288
  • Fax: 503-234-8613
Mailing address:
  • Phone: 503-234-4288
  • Fax: 503-234-8613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number6243
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License Number6243
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number6243
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number6243
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: