Provider Demographics
NPI:1780705905
Name:WILSON, MICHAEL A (DC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
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 88
Mailing Address - Street 2:
Mailing Address - City:CAVE CITY
Mailing Address - State:AR
Mailing Address - Zip Code:72521-0088
Mailing Address - Country:US
Mailing Address - Phone:870-283-5553
Mailing Address - Fax:870-283-5133
Practice Address - Street 1:619 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:CAVE CITY
Practice Address - State:AR
Practice Address - Zip Code:72521
Practice Address - Country:US
Practice Address - Phone:870-283-5553
Practice Address - Fax:870-283-5133
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1159111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR16061000040OtherQUAL CHOICE
AR59659OtherBLUE CROSS BLUE SHIELD
AR16061000040OtherQUAL CHOICE
AR59659OtherBLUE CROSS BLUE SHIELD