Provider Demographics
NPI:1275683831
Name:WISE, ANDREA (DPT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:WAHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1709 CALDWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-1729
Mailing Address - Country:US
Mailing Address - Phone:208-489-4480
Mailing Address - Fax:208-489-4073
Practice Address - Street 1:1709 CALDWELL BLVD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-1729
Practice Address - Country:US
Practice Address - Phone:208-489-4480
Practice Address - Fax:208-489-4073
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2137225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010159755OtherREGENCE BLUE SHIELD
IDTD413OtherBLUE CROSS OF IDAHO
ID807708700Medicaid
ID807708700Medicaid