Provider Demographics
NPI:1790727287
Name:WHEELER, REBECCA RUSSELL
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:RUSSELL
Last Name:WHEELER
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 1:1600 W 40TH AVE
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6301
Mailing Address - Country:US
Mailing Address - Phone:870-541-7524
Mailing Address - Fax:870-541-7543
Practice Address - Street 1:1600 W 40TH AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6301
Practice Address - Country:US
Practice Address - Phone:870-541-7524
Practice Address - Fax:870-541-7543
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC8173207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR126119001Medicaid
ARC87109Medicare UPIN
AR5J546Medicare ID - Type Unspecified