Provider Demographics
NPI:1174290811
Name:WILSON, KOBE (BA)
Entity Type:Individual
Prefix:
First Name:KOBE
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6210 BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72209-4728
Mailing Address - Country:US
Mailing Address - Phone:501-265-0302
Mailing Address - Fax:501-265-0300
Practice Address - Street 1:6210 BASELINE RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-4728
Practice Address - Country:US
Practice Address - Phone:501-265-0302
Practice Address - Fax:501-265-0300
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-29
Last Update Date:2021-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator