Individual
BRETT LEE WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
2521 GLENN HENDREN DR STE 204, LIBERTY, MO 64068-3388
(816) 781-6066
Mailing address
1733 COUNTY ROAD 200, EMPORIA, KS 66801-7672
(620) 343-8044
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
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