Provider Demographics
NPI:1386996056
Name:WILKS, BRENDA KAY (PA-C)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:KAY
Last Name:WILKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:KAY
Other - Last Name:LUTHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1529
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:WA
Mailing Address - Zip Code:99006-1529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:509 EAST D STREET
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:WA
Practice Address - Zip Code:99006-1529
Practice Address - Country:US
Practice Address - Phone:509-276-5005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60314280363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant