Provider Demographics
NPI:1740273283
Name:WILSON, BRYAN D (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:D
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 11157
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64119-0157
Mailing Address - Country:US
Mailing Address - Phone:913-234-1350
Mailing Address - Fax:913-234-1108
Practice Address - Street 1:2800 CLAY EDWARDS DR
Practice Address - Street 2:
Practice Address - City:NORTH KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-3220
Practice Address - Country:US
Practice Address - Phone:816-346-7220
Practice Address - Fax:816-346-7242
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR1K78207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
15633077OtherBCBS KC MO
MO6781212Medicare PIN
E60147Medicare UPIN