Healthcare Provider Details

I. General information

NPI: 1598155129
Provider Name (Legal Business Name): TANYA WILKE FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2015
Last Update Date: 04/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1427 JEFFERSON AVE SUITE 202
ENUMCLAW WA
98022-3649
US

IV. Provider business mailing address

1427 JEFFERSON AVE SUITE 202
ENUMCLAW WA
98022-3649
US

V. Phone/Fax

Practice location:
  • Phone: 360-825-2849
  • Fax: 360-825-5381
Mailing address:
  • Phone: 360-825-2849
  • Fax: 360-825-5381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberMD60090609
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0251251
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerSTATE L&I
# 2
Identifier0274400
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerSTATE L&I

VIII. Authorized Official

Name: DR. TANYA WILKE
Title or Position: PHYSICIAN
Credential: MD
Phone: 360-825-2849