Provider Demographics
NPI:1396052866
Name:WILDMAN, MARY ANNE (MSPT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:WILDMAN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SAINT VINCENT CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5415
Mailing Address - Country:US
Mailing Address - Phone:501-663-6455
Mailing Address - Fax:501-978-1473
Practice Address - Street 1:5 SAINT VINCENT CIR STE 100
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5415
Practice Address - Country:US
Practice Address - Phone:501-663-6455
Practice Address - Fax:501-978-1473
Is Sole Proprietor?:No
Enumeration Date:2010-09-07
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2010225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR183722721Medicaid