Provider Demographics
NPI:1558809475
Name:WRINKLES, BROCK HARRISON (PA)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:HARRISON
Last Name:WRINKLES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 TRENT JONES CV
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-4611
Mailing Address - Country:US
Mailing Address - Phone:501-599-8400
Mailing Address - Fax:501-623-5598
Practice Address - Street 1:1801 CENTRAL AVE STE A
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-6800
Practice Address - Country:US
Practice Address - Phone:501-623-5598
Practice Address - Fax:501-623-5516
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-11
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2017-010363AM0700X
ARPA-720207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1139067OtherNCCPA
ARPA-720OtherARKANSAS STATE MEDICAL BOARD
ARPA-720OtherARKANSAS STATE MEDICAL BOARD