Basic Information
| Provider Information | |||||||||
| NPI: | 1194726307 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1733 COUNTY ROAD 200 | ||||||||
| Address2: | |||||||||
| City: | EMPORIA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 668017672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6203438044 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2521 GLENN HENDREN DR STE 204 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640683388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167816066 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 06/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 15-00245 | KS | N | Allopathic & Osteopathic Physicians | Surgery | 363AS0400X | 2009014905 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 970000628 | 01 | KS | PALMETTO RR MEDICARE | OTHER | 100002860A | 05 | KS | MEDICAID | 50797021 | 01 | MO | BCBS | OTHER |