Provider Demographics
NPI:1598141525
Name:WILSON, SHAWN
Entity Type:Individual
Prefix:MS
First Name:SHAWN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 W EDEN CIR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-6931
Mailing Address - Country:US
Mailing Address - Phone:479-445-2781
Mailing Address - Fax:
Practice Address - Street 1:880 W EDEN CIR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-6931
Practice Address - Country:US
Practice Address - Phone:479-445-2781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR208211783171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR208211783Medicaid