Healthcare Provider Details

I. General information

NPI: 1619370087
Provider Name (Legal Business Name): ANTHONY WILKERSON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2014
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2232 WILBORN AVE SUITE A
SOUTH BOSTON VA
24592-1662
US

IV. Provider business mailing address

1060 CARRIAGE END WAY
SOUTH BOSTON VA
24592-6521
US

V. Phone/Fax

Practice location:
  • Phone: 434-517-3355
  • Fax: 434-572-2510
Mailing address:
  • Phone: 434-579-0935
  • Fax: 434-572-2510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024172092
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: