Healthcare Provider Details

I. General information

NPI: 1457139594
Provider Name (Legal Business Name): BLAKE R WILCOCK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2023
Last Update Date: 07/24/2024
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 WHEELING AVE FL 3
GLEN DALE WV
26038-1660
US

IV. Provider business mailing address

1 MEDICAL PARK
WHEELING WV
26003-6379
US

V. Phone/Fax

Practice location:
  • Phone: 304-845-0100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: