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General NPI Number Information
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NPI Number | 1962844522
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Entity Type | Individual
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Provider Name | GARY MARK WILSON NP
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Gender | Male
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Dates
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Enumeration Date | 07/24/2013
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Last Update Date | 09/12/2024
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Provider Practice Location Address
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Address Line | 4901 E JOHNSON AVE
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City | JONESBORO
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State | AR
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Zip | 72405-8417
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Country | US
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Telephone | 870-936-8000
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Fax | 870-934-3659
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Provider Business Mailing Address
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Address Line | PO BOX 1960
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City | JONESBORO
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State | AR
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Zip | 72403-1960
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Country | US
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Telephone | 870-936-8000
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Fax | 870-934-3659
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 2013026042
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | A004043
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License Number State | AR
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