Provider Demographics
NPI:1417462151
Name:WISE, ANDREA DAWN (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:DAWN
Last Name:WISE
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 SKELLY ST
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:KS
Mailing Address - Zip Code:67042-2338
Mailing Address - Country:US
Mailing Address - Phone:316-734-0443
Mailing Address - Fax:
Practice Address - Street 1:100 W 16TH ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:KS
Practice Address - Zip Code:67045-1064
Practice Address - Country:US
Practice Address - Phone:620-583-0562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS77871363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care