Provider Demographics
NPI:1265015572
Name:WISE, DALTON ANDREW
Entity Type:Individual
Prefix:
First Name:DALTON
Middle Name:ANDREW
Last Name:WISE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2403 LOUISIANA ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72206-2239
Mailing Address - Country:US
Mailing Address - Phone:501-580-2291
Mailing Address - Fax:
Practice Address - Street 1:1000 W CARSON ST
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2059
Practice Address - Country:US
Practice Address - Phone:424-306-6219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program