Provider Demographics
NPI:1356316269
Name:NORRIS, WILTON J (ANP)
Entity Type:Individual
Prefix:MR
First Name:WILTON
Middle Name:J
Last Name:NORRIS
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 NORTHTOWN
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-3105
Mailing Address - Country:US
Mailing Address - Phone:870-425-3131
Mailing Address - Fax:870-425-3136
Practice Address - Street 1:614 NORTHTOWN
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3105
Practice Address - Country:US
Practice Address - Phone:870-425-3131
Practice Address - Fax:870-425-3136
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01449ANP207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR140590758Medicaid