Provider Demographics
NPI:1063577682
Name:WILSON, JAMES JR
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1679 HIGHWAY 243 SOUTH
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:AR
Mailing Address - Zip Code:72360
Mailing Address - Country:US
Mailing Address - Phone:870-295-3557
Mailing Address - Fax:870-295-3686
Practice Address - Street 1:1679 HIGHWAY 243 SOUTH
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:AR
Practice Address - Zip Code:72360
Practice Address - Country:US
Practice Address - Phone:870-295-3557
Practice Address - Fax:870-295-3686
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR329033747P1801X
AR101177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No177F00000XOther Service ProvidersLodging
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR121812732Medicaid