Provider Demographics
NPI:1558130997
Name:WILKINSON, BRAXTON REID
Entity type:Individual
Prefix:
First Name:BRAXTON
Middle Name:REID
Last Name:WILKINSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3241 WESTERN BRANCH BLVD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-5260
Mailing Address - Country:US
Mailing Address - Phone:757-967-8622
Mailing Address - Fax:757-686-0541
Practice Address - Street 1:1060 FIRST COLONIAL RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3002
Practice Address - Country:US
Practice Address - Phone:757-967-8622
Practice Address - Fax:757-686-0541
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-27
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110010251363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant