Provider Demographics
NPI:1215189618
Name:WILSON, BRANDYE NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:BRANDYE
Middle Name:NICOLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-3115
Mailing Address - Country:US
Mailing Address - Phone:662-534-2227
Mailing Address - Fax:662-534-2330
Practice Address - Street 1:125 GOODMAN RD W STE D
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9481
Practice Address - Country:US
Practice Address - Phone:662-932-3560
Practice Address - Fax:662-534-2330
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA362363AM0700X
MSPA00448363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS873993OtherMS MEDICARE
MS00133522Medicaid