Provider Demographics
NPI:1770547580
Name:WILSON, BRANDY CRUSE (PA-C)
Entity type:Individual
Prefix:MS
First Name:BRANDY
Middle Name:CRUSE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BRANDY
Other - Middle Name:LYNN
Other - Last Name:CRUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4414 LAKE BOONE TRL STE 108
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7522
Mailing Address - Country:US
Mailing Address - Phone:919-784-2300
Mailing Address - Fax:
Practice Address - Street 1:4414 LAKE BOONE TRL STE 108
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7522
Practice Address - Country:US
Practice Address - Phone:919-784-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000104058363A00000X
NC104058363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC189Q6OtherBCBSNC
NC1770547580Medicaid
NC189Q6OtherBCBSNC