Provider Demographics
NPI:1578871935
Name:WILSON, BRITTANY L (PA)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BRITTANY
Other - Middle Name:L
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2960 MACK RD STE 201
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-5300
Mailing Address - Country:US
Mailing Address - Phone:513-874-8111
Mailing Address - Fax:513-860-6992
Practice Address - Street 1:2960 MACK RD STE 201
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5300
Practice Address - Country:US
Practice Address - Phone:513-874-8111
Practice Address - Fax:513-860-6992
Is Sole Proprietor?:No
Enumeration Date:2010-09-20
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1883363AM0700X
OH50.004924RX363AM0700X, 363AM0700X
TN2305363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical