Provider Demographics
NPI:1356301105
Name:BRYS-WILSON, JESSICA (PAC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BRYS-WILSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7867
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-0867
Mailing Address - Country:US
Mailing Address - Phone:252-442-1807
Mailing Address - Fax:252-442-1649
Practice Address - Street 1:10589 E NC 97
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27803-9208
Practice Address - Country:US
Practice Address - Phone:252-442-1807
Practice Address - Fax:252-442-1649
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001000252363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC416456OtherWELLPATH ID
NC213660OtherMEDCOST ID
NC7708741OtherAETNA ID
NC213660OtherMEDCOST ID
NCP00335449Medicare PIN
NC7708741OtherAETNA ID