Provider Demographics
NPI:1396201935
Name:WISE, BLAKELY DAVID (PA)
Entity Type:Individual
Prefix:
First Name:BLAKELY
Middle Name:DAVID
Last Name:WISE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20036 ZION AVE
Practice Address - Street 2:STE 100
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-8435
Practice Address - Country:US
Practice Address - Phone:704-801-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08866363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty