=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336737337
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALYSSA WILKINS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2021
-----------------------------------------------------
Last Update Date | 05/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3721 WILLIAMS DR
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78628-2401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-869-7310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 W 10TH ST
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78621-2110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA13991
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------