Provider Demographics
NPI:1013103001
Name:WILSON, BRYANT THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:THOMAS
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 1:3264 N EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9746
Mailing Address - Country:US
Mailing Address - Phone:616-363-7339
Mailing Address - Fax:616-361-5828
Practice Address - Street 1:3264 N EVERGREEN DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9746
Practice Address - Country:US
Practice Address - Phone:616-363-7339
Practice Address - Fax:616-361-5828
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004603363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM74460373Medicare PIN