Healthcare Provider Details

I. General information

NPI: 1154776409
Provider Name (Legal Business Name): AMY WILSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2016
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 ROGERS AVE
FORT SMITH AR
72903-4100
US

IV. Provider business mailing address

104 WALL ST
POTEAU OK
74953-4405
US

V. Phone/Fax

Practice location:
  • Phone: 479-314-5175
  • Fax:
Mailing address:
  • Phone: 918-647-8635
  • Fax: 918-635-3191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE-12276
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number6276
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberE-12276
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: