Provider Demographics
NPI:1679532626
Name:WILKES ANESTHESIA ASSOCIATES PA
Entity type:Organization
Organization Name:WILKES ANESTHESIA ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:EBONY
Authorized Official - Middle Name:
Authorized Official - Last Name:COULTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:844-212-1610
Mailing Address - Street 1:1092 TOWN N COUNTRY DR
Mailing Address - Street 2:
Mailing Address - City:WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28697-7512
Mailing Address - Country:US
Mailing Address - Phone:866-434-2745
Mailing Address - Fax:336-434-6478
Practice Address - Street 1:1370 W D ST
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3506
Practice Address - Country:US
Practice Address - Phone:336-651-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-20
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89013WGMedicaid
NC2329772Medicare ID - Type UnspecifiedGROUP NUMBER