Healthcare Provider Details

I. General information

NPI: 1275745010
Provider Name (Legal Business Name): AMY CAROLE WILSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S UNION ST
DEWITT AR
72042-2727
US

IV. Provider business mailing address

1310 S ROY ST
DEWITT AR
72042-2992
US

V. Phone/Fax

Practice location:
  • Phone: 870-946-1606
  • Fax: 870-946-2937
Mailing address:
  • Phone: 870-946-3497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA1463
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: