Provider Demographics
NPI:1205693942
Name:WILSON-ODOM, BRANDY ROSE-CHARLENE (PA-C)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:ROSE-CHARLENE
Last Name:WILSON-ODOM
Suffix:
Gender:F
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 1:615 BAY HILL DR APT 6
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-5644
Mailing Address - Country:US
Mailing Address - Phone:231-357-1764
Mailing Address - Fax:
Practice Address - Street 1:125 NATIONWIDE DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-4272
Practice Address - Country:US
Practice Address - Phone:434-200-3908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009901363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant