Provider Demographics
NPI:1821495417
Name:WILSON, BROOK ASHLEY (PA)
Entity Type:Individual
Prefix:
First Name:BROOK
Middle Name:ASHLEY
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12697 E 51ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-6236
Mailing Address - Country:US
Mailing Address - Phone:918-505-3344
Mailing Address - Fax:918-505-3290
Practice Address - Street 1:6802 S OLYMPIA AVE W
Practice Address - Street 2:300
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74132-1823
Practice Address - Country:US
Practice Address - Phone:918-749-0762
Practice Address - Fax:918-744-4246
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-25
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2417207L00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology