Provider Demographics
NPI:1174292783
Name:WILKERSON, GARY N (MED)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:N
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 BOUNDARY AVE
Mailing Address - Street 2:
Mailing Address - City:ONANCOCK
Mailing Address - State:VA
Mailing Address - Zip Code:23417
Mailing Address - Country:US
Mailing Address - Phone:267-258-3894
Mailing Address - Fax:757-709-7052
Practice Address - Street 1:33 BOUNDARY AVE
Practice Address - Street 2:
Practice Address - City:ONANCOCK
Practice Address - State:VA
Practice Address - Zip Code:23417
Practice Address - Country:US
Practice Address - Phone:267-258-3894
Practice Address - Fax:757-709-7052
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0718000262101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)