Provider Demographics
NPI:1043775414
Name:WILSON, BRANDON JAMES (PA-C)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:JAMES
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 CEDARWOOD CT
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36870-4801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:USCG BASE KODIAK ROCKMORE-KING CLINIC
Practice Address - Street 2:200 ALBATROSS AVE BLDG N-46
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6810
Practice Address - Country:US
Practice Address - Phone:907-487-5757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-09
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA01268363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant