MEDICARE: BRETT LEE WILSON PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	15-00245	KS
2	363AS0400X	Surgical Physician Assistant	2009014905	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	970000628	OTHER	KS	PALMETTO RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	50797021	OTHER	MO	BCBS

General Provider Information

NPI Number	:	1194726307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRETT LEE WILSON PA

Provider Business Mailing Address
First Line	:	1733 COUNTY ROAD 200
Second Line	:
City	:	EMPORIA
State	:	KS
Zip	:	66801-7672
Country	:	US
Telephone Number	:	620-343-8044
Fax Number	:

Provider Business Practice Location Address
First Line	:	2521 GLENN HENDREN DR STE 204
Second Line	:
City	:	LIBERTY
State	:	MO
Zip	:	64068-3388
Country	:	US
Telephone Number	:	816-781-6066
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	06/19/2019

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Directions to “ BRETT LEE WILSON PA” Practice Location

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