Provider Demographics
NPI:1376632364
Name:WISE, JOHN A (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:WISE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6005 PARK AVE
Mailing Address - Street 2:SUITE 802
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5202
Mailing Address - Country:US
Mailing Address - Phone:901-236-0508
Mailing Address - Fax:901-682-2143
Practice Address - Street 1:6005 PARK AVE
Practice Address - Street 2:SUITE 802
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5202
Practice Address - Country:US
Practice Address - Phone:901-236-0508
Practice Address - Fax:901-682-2143
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1395207P00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPENDINGMedicaid
TNPENDINGMedicaid