Provider Demographics
NPI:1992228753
Name:WILSON, MYRA B (PA-C)
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:B
Last Name:WILSON
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 GENN DR
Mailing Address - Street 2:
Mailing Address - City:WAMEGO
Mailing Address - State:KS
Mailing Address - Zip Code:66547-1179
Mailing Address - Country:US
Mailing Address - Phone:785-456-2295
Mailing Address - Fax:
Practice Address - Street 1:711 GENN DR
Practice Address - Street 2:
Practice Address - City:WAMEGO
Practice Address - State:KS
Practice Address - Zip Code:66547-1179
Practice Address - Country:US
Practice Address - Phone:785-456-2295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-02039363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant