Basic Information
| Provider Information | |||||||||
| NPI: | 1164942892 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILKENS | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | DOUGLAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19305 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282199305 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1225 HARDING PL | ||||||||
| Address2: | STE 2100 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282042826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043319669 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2017 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 5009412 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363L00000X | 5009412 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.