Healthcare Provider Details

I. General information

NPI: 1881241552
Provider Name (Legal Business Name): KARY WILSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2019
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 4TH ST
ALEXANDRIA LA
71301-8421
US

IV. Provider business mailing address

1053 BLACKMON RD
LEESVILLE LA
71446-5954
US

V. Phone/Fax

Practice location:
  • Phone: 318-769-3000
  • Fax:
Mailing address:
  • Phone: 337-208-2384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number320673
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: