Provider Demographics
NPI:1043675515
Name:WISE, DAVID (RN)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:WISE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N2454 BANNECKER DR
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-9029
Mailing Address - Country:US
Mailing Address - Phone:126-241-2534
Mailing Address - Fax:
Practice Address - Street 1:728 WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-1826
Practice Address - Country:US
Practice Address - Phone:126-221-5908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI225762-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse