Individual
MS. SHAWN WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
880 W EDEN CIR, FAYETTEVILLE, AR 72701-6931
(479) 445-2781
Mailing address
880 W EDEN CIR, FAYETTEVILLE, AR 72701-6931
(479) 445-2781
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
208211783
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
208211783
—
AR
Enumeration date
07/31/2015
Last updated
07/31/2015
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