Provider Demographics
NPI:1437651601
Name:WILSON, LISA C
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:WILSON
Suffix:
Gender:F
Credentials:
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 21850
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71903-1850
Mailing Address - Country:US
Mailing Address - Phone:501-922-2217
Mailing Address - Fax:
Practice Address - Street 1:4419 N HIGHWAY 7 STE 200
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71909-9301
Practice Address - Country:US
Practice Address - Phone:501-922-2217
Practice Address - Fax:501-922-4216
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005516363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner