Provider Demographics
NPI:1164663449
Name:WISE, A MICHELLE (FNP)
Entity Type:Individual
Prefix:
First Name:A
Middle Name:MICHELLE
Last Name:WISE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:A. MICHELLE
Other - Middle Name:
Other - Last Name:WISE-EASTERGARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:224 AVERY JONES LN APT 202
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-0155
Mailing Address - Country:US
Mailing Address - Phone:864-501-7603
Mailing Address - Fax:
Practice Address - Street 1:739 GALLERIA BLVD STE 112
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-5785
Practice Address - Country:US
Practice Address - Phone:803-547-4343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-16
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2787363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCC1783365OtherMEDICARE PIN