Provider Demographics
NPI:1942441225
Name:WILSON-BROWN, LAURA L (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:WILSON-BROWN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:L
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7309 N KNOXVILLE AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2085
Mailing Address - Country:US
Mailing Address - Phone:309-691-6225
Mailing Address - Fax:309-691-7635
Practice Address - Street 1:7309 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2085
Practice Address - Country:US
Practice Address - Phone:309-692-9898
Practice Address - Fax:309-692-9055
Is Sole Proprietor?:No
Enumeration Date:2009-03-16
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003443363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085003443OtherLICENSE