Healthcare Provider Details

I. General information

NPI: 1972365963
Provider Name (Legal Business Name): BROOKE WILSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2024
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16538 W 159TH TER
OLATHE KS
66062-3924
US

IV. Provider business mailing address

16538 W 159TH TER
OLATHE KS
66062-3924
US

V. Phone/Fax

Practice location:
  • Phone: 913-445-8660
  • Fax:
Mailing address:
  • Phone: 913-445-8660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2025039987
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: