Provider Demographics
NPI:1417559782
Name:WISE, JUSTIN (ND)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:WISE
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 MONTGOMERY DR STE 104
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-6617
Mailing Address - Country:US
Mailing Address - Phone:480-310-1565
Mailing Address - Fax:
Practice Address - Street 1:1551 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-3568
Practice Address - Country:US
Practice Address - Phone:707-586-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath