Provider Demographics
NPI:1669771267
Name:WILKS, AMRU OKETA NICOLE (RPA-C)
Entity type:Individual
Prefix:MISS
First Name:AMRU
Middle Name:OKETA NICOLE
Last Name:WILKS
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17742 136TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-4014
Mailing Address - Country:US
Mailing Address - Phone:718-316-3972
Mailing Address - Fax:
Practice Address - Street 1:17742 136TH AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-4014
Practice Address - Country:US
Practice Address - Phone:718-316-3972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014713363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1090221OtherNATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS (NCCPA)
NY014713OtherNEW YORK STATE PHYSICIAN ASSISTANT LICENSE