Provider Demographics
NPI:1063485670
Name:WISDOM, KEVIN (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WISDOM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1608
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-1608
Mailing Address - Country:US
Mailing Address - Phone:479-521-2752
Mailing Address - Fax:479-444-6942
Practice Address - Street 1:3317 N WIMBERLY DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4056
Practice Address - Country:US
Practice Address - Phone:479-521-2752
Practice Address - Fax:479-444-6942
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2490225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP00162005OtherRAILROAD MEDICARE
AR5X947Medicare PIN
ARP00162005OtherRAILROAD MEDICARE