Provider Demographics
NPI:1720519812
Name:WILANSKY, JAQUELYN RISA (MD)
Entity Type:Individual
Prefix:DR
First Name:JAQUELYN
Middle Name:RISA
Last Name:WILANSKY
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 1:5555 W THUNDERBIRD RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4622
Mailing Address - Country:US
Mailing Address - Phone:479-521-8260
Mailing Address - Fax:
Practice Address - Street 1:2158 BUTTERFIELD COACH RD STE 100
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-9142
Practice Address - Country:US
Practice Address - Phone:479-757-5026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-12048207P00000X, 207Q00000X
390200000X
AZ60377208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program