Individual
MS. BRANDY CRUSE WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
4414 LAKE BOONE TRL STE 108, RALEIGH, NC 27607-7522
(919) 784-2300
Mailing address
4414 LAKE BOONE TRL STE 108, RALEIGH, NC 27607-7522
(919) 784-2300
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
000104058
NC
363A00000X
Physician Assistant
Primary
104058
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
189Q6
BCBSNC
NC
Enumeration date
04/17/2006
Last updated
10/20/2021
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