Provider Demographics
NPI:1336203348
Name:WILBANKS, STACY LEANN (MD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LEANN
Last Name:WILBANKS
Suffix:
Gender:F
Credentials:MD
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 1960
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1960
Mailing Address - Country:US
Mailing Address - Phone:870-936-8000
Mailing Address - Fax:870-336-3214
Practice Address - Street 1:1111 WINDOVER RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6159
Practice Address - Country:US
Practice Address - Phone:870-936-8000
Practice Address - Fax:870-336-3214
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-4415207P00000X
ARE4415207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR166880001Medicaid
AR166880001Medicaid
ARI32692Medicare UPIN
ARBW9187015OtherDEA