Individual
BRETT LEE WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
15-00245
KS
363AS0400X
Surgical Physician Assistant
Primary
2009014905
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100002860A
—
KS
01
—
50797021
BCBS
MO
01
—
970000628
PALMETTO RR MEDICARE
KS
Enumeration date
08/10/2005
Last updated
06/19/2019
Update your record
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