Provider Demographics
NPI:1063412369
Name:WILKA, KENNETH R (ATC)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:WILKA
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W63N541 HANOVER AVE
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-1917
Mailing Address - Country:US
Mailing Address - Phone:262-375-2195
Mailing Address - Fax:262-375-2273
Practice Address - Street 1:W63N541 HANOVER AVE
Practice Address - Street 2:
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-1917
Practice Address - Country:US
Practice Address - Phone:262-375-2195
Practice Address - Fax:262-375-2273
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI600-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer