Provider Demographics
NPI:1063949691
Name:MCKNIGHT, WILSON MATTHEW (ATC)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:MATTHEW
Last Name:MCKNIGHT
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 KIMBERLY DRIVE
Mailing Address - Street 2:
Mailing Address - City:VILONIA
Mailing Address - State:AR
Mailing Address - Zip Code:72173
Mailing Address - Country:US
Mailing Address - Phone:501-472-4442
Mailing Address - Fax:
Practice Address - Street 1:1164 MAIN STREET
Practice Address - Street 2:
Practice Address - City:VILONIA
Practice Address - State:AR
Practice Address - Zip Code:72173-7217
Practice Address - Country:US
Practice Address - Phone:501-472-4442
Practice Address - Fax:501-472-4442
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR6772255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer