Individual
BRANDYE NICOLE WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.A.
Contact information
Practice address
125 GOODMAN RD W STE D, SOUTHAVEN, MS 38671-9481
(662) 932-3560
(662) 534-2330
Mailing address
206 OXFORD RD, NEW ALBANY, MS 38652-3115
(662) 534-2227
(662) 534-2330
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA00448
MS
363AM0700X
Medical Physician Assistant
PA362
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00133522
—
MS
01
—
873993
MS MEDICARE
MS
Enumeration date
10/16/2008
Last updated
09/28/2020
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