Healthcare Provider Details

I. General information

NPI: 1558874818
Provider Name (Legal Business Name): MATTHEW L WOOD APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2017
Last Update Date: 11/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 ROSS AVE
MONTICELLO AR
71655-4250
US

IV. Provider business mailing address

128 ROSS AVE
MONTICELLO AR
71655-4250
US

V. Phone/Fax

Practice location:
  • Phone: 870-723-0219
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA005413
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR091983
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: