Provider Demographics
NPI:1861695611
Name:TRACI L WILKERSON AUD INC PC
Entity type:Organization
Organization Name:TRACI L WILKERSON AUD INC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:918-682-1515
Mailing Address - Street 1:3312 W OKMULGEE ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-5069
Mailing Address - Country:US
Mailing Address - Phone:918-682-1515
Mailing Address - Fax:918-682-1598
Practice Address - Street 1:3312 W OKMULGEE ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-5069
Practice Address - Country:US
Practice Address - Phone:918-682-1515
Practice Address - Fax:918-682-1598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK144231HA2500X, 237600000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology SupplierGroup - Single Specialty
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100676030FOtherDHS - DDSD
OK100676030COtherDHS - DDSD
OKDC 0957OtherMEDICARE RAILROAD
OK100676030EOtherDHS - DDSD
OK101410900OtherDEPARTMENT OF LABOR
OK100676030DOtherDHS - DDSD