Provider Demographics
NPI:1417787771
Name:WILSON, KYRA (PA)
Entity type:Individual
Prefix:
First Name:KYRA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21212 NORTHWEST FWY
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-5884
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21212 NORTHWEST FWY
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-5884
Practice Address - Country:US
Practice Address - Phone:832-912-4481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-02
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA18419363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program