MEDICARE: BROCK HARRISON WRINKLES PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PT2017-010	AR
2	207QA0401X	Addiction Medicine (Family Medicine) Physician	PA-720	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1139067	OTHER		NCCPA
2	PA-720	OTHER	AR	ARKANSAS STATE MEDICAL BOARD

General Provider Information

NPI Number	:	1558809475
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROCK HARRISON WRINKLES PA

Provider Business Mailing Address
First Line	:	6 TRENT JONES CV
Second Line	:
City	:	SHERWOOD
State	:	AR
Zip	:	72120-4611
Country	:	US
Telephone Number	:	501-599-8400
Fax Number	:	501-623-5598

Provider Business Practice Location Address
First Line	:	1801 CENTRAL AVE STE A
Second Line	:
City	:	HOT SPRINGS
State	:	AR
Zip	:	71901-6800
Country	:	US
Telephone Number	:	501-623-5598
Fax Number	:	501-623-5516

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/11/2017
Last Update Date	:	03/21/2023

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Directions to “ BROCK HARRISON WRINKLES PA” Practice Location

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