Provider Demographics
NPI:1508100553
Name:WILSON, MISTI ARLANE (PTA)
Entity type:Individual
Prefix:
First Name:MISTI
Middle Name:ARLANE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3819 RIDGEMONT EST
Mailing Address - Street 2:
Mailing Address - City:MULBERRY
Mailing Address - State:AR
Mailing Address - Zip Code:72947-9174
Mailing Address - Country:US
Mailing Address - Phone:479-414-2810
Mailing Address - Fax:
Practice Address - Street 1:2801 OLD GREENWOOD RD STE 14
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4560
Practice Address - Country:US
Practice Address - Phone:479-222-1425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2577225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant