Provider Demographics
NPI:1487044962
Name:WILFORD, BOONE (APRN)
Entity Type:Individual
Prefix:
First Name:BOONE
Middle Name:
Last Name:WILFORD
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 TROPHY CT
Mailing Address - Street 2:
Mailing Address - City:COTTER
Mailing Address - State:AR
Mailing Address - Zip Code:72626-9238
Mailing Address - Country:US
Mailing Address - Phone:417-849-0562
Mailing Address - Fax:
Practice Address - Street 1:23 TROPHY CT
Practice Address - Street 2:
Practice Address - City:COTTER
Practice Address - State:AR
Practice Address - Zip Code:72626-9238
Practice Address - Country:US
Practice Address - Phone:417-849-0562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015001252363L00000X
WAAP61495401363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1487044962Medicaid
MO420020610Medicaid