Individual
KEVIN WISDOM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.T.
Contact information
Practice address
3317 N WIMBERLY DR, FAYETTEVILLE, AR 72703-4056
(479) 521-2752
(479) 444-6942
Mailing address
PO BOX 1608, FAYETTEVILLE, AR 72702-1608
(479) 521-2752
(479) 444-6942
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT2490
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
P00162005
RAILROAD MEDICARE
AR
Enumeration date
02/13/2006
Last updated
12/14/2010
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