Basic Information
| Provider Information | |||||||||
| NPI: | 1356301105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYS-WILSON | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7867 | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278040867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524421807 | ||||||||
| FaxNumber: | 2524421649 | ||||||||
| Practice Location | |||||||||
| Address1: | 10589 E NC 97 | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278039208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524421807 | ||||||||
| FaxNumber: | 2524421649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 04/11/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 001000252 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 416456 | 01 | NC | WELLPATH ID | OTHER | 213660 | 01 | NC | MEDCOST ID | OTHER | 7708741 | 01 | NC | AETNA ID | OTHER |