Provider Demographics
NPI:1053950246
Name:WILKERSON, GREGORY (AGACNP-BC)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1269 NATHAN MAULDIN DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7249
Mailing Address - Country:US
Mailing Address - Phone:678-468-8672
Mailing Address - Fax:
Practice Address - Street 1:595 HURRICANE SHOALS RD NW
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8761
Practice Address - Country:US
Practice Address - Phone:770-995-7802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-05
Last Update Date:2020-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN219542363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner