Basic Information
| Provider Information | |||||||||
| NPI: | 1487174744 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILKINSON | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | ACNP-AG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 W WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615202444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096475240 | ||||||||
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| Practice Location | |||||||||
| Address1: | 210 W WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615202444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096475240 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2017 | ||||||||
| LastUpdateDate: | 06/27/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 209016115 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 209016115 | 01 | IL | ILLINOIS APN LICENSE | OTHER |