Individual
DR. LARRY T WILCKEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
151 W 200 N, VERNAL, UT 84078-1907
(435) 789-3342
Mailing address
3618 DRY FORK CANYON RD, VERNAL, UT 84078-9404
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
158064-1205
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
05135
—
UT
05
—
H1232
—
NM
Enumeration date
03/12/2007
Last updated
03/16/2010
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