Provider Demographics
NPI:1023321882
Name:BENNETT WILKE, COURTNEY LEE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:LEE
Last Name:BENNETT WILKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 PAT HARALSON DR UNIT 1
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-8454
Mailing Address - Country:US
Mailing Address - Phone:706-745-8790
Mailing Address - Fax:706-745-8842
Practice Address - Street 1:401 PAT HARALSON DR UNIT 1
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-8454
Practice Address - Country:US
Practice Address - Phone:706-745-8790
Practice Address - Fax:706-745-8842
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105489363A00000X
GA12767363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003175470BMedicaid
GA12767OtherGEORGIA COMPOSITE MEDICAL BOARD